General clinical examination methods in surgery

Goals and key stages of examination

Any surgical examination must be performed systematically rather than chaotically. The physician needs to determine which specific organ is affected, and ascertain the localization, extent, nature, and etiology of the pathological process. This allows not only establishing the diagnosis and understanding the pathogenesis, but also assessing the impact of the disease on the entire organism as a whole.

The examination process includes four key stages:

1. Eliciting patient complaints.
2. Taking the anamnesis.
3. Examination of local status (status localis).
4. Establishing the diagnosis and final choice of treatment tactics.

Assessment of body posture and skeletal status

The external posture of the patient or a specific organ (shape, mobility, coloration) provides insight into the type of disease, its duration, and severity. For example, if the patient's spine is immobile and they support their head or torso with their hands, a spinal disease such as spondylitis can be suspected. Unusual postures can also be caused by paralysis, muscle contractures, and skeletal changes.

All patients, except for the severely ill, must be examined in two positions: standing and lying down. This is critical for hernias, hydroceles, or lower extremity pathologies. Gravity causes the contents of the hernia sac or fluid to shift (descending in the upright position and returning in the horizontal position).

When assessing the skeleton, the physician takes into account the dynamics of changes:

• Acute: occur rapidly (fractures, dislocations, subluxations, ligament sprains).
• Gradual: develop over time (deforming and destructive inflammations of joints and bones).

A critical criterion for diagnosing injuries is the assessment of the limb axis. The axis of the upper extremity conventionally passes through the center of the humeral head, the head of the radius, and the ulna. The normal axis of the lower extremity is projected from the anterior superior iliac spine (spina iliaca anterior superior) through the middle of the patella to the space between the 1st and 2nd toes.

Characteristics of space-occupying lesions

During inspection, the physician must differentiate a general swelling, which may be caused by edema or inflammation, from a true tumor (tumor). A number of specific signs are evaluated for neoplasms.

Some tumors exhibit mobility with movements (for example, thyroid lesions move during swallowing). The shape of the tumor can be cylindrical, pear-shaped, ovoid, or irregular. A rounded shape is most characteristic of atheromas, cysts, and dermoids.

It is important to assess the base of the lesion:

• Grows on a stalk: most often benign polypoid formations.
• Grows on a broad base with skin changes and is poorly distinguishable from surrounding tissues: characteristic of malignant tumors.

The dimensions of the pathological focus are described either by a comparative method (associating it with a bean, nut, orange, chicken egg, or a child's head) or by an exact method—measuring in centimeters. If the lesion is a fluid-filled sac (e.g., hydrocele of the testis — hydrocele), the method of transillumination is used. Transillumination of tissues indicates that the internal content is serous fluid.

Skin changes, circulation, and scars

The color and condition of the skin are a mirror of general and local processes in the body. A pink or pale color is considered normal. An earthy skin tint often accompanies emaciation, while a straw-yellow color is a sign of pronounced intoxication and cachexia in malignant neoplasms.

Local circulatory changes manifest in various ways:

• Local pallor: acute impairment of arterial blood flow.
• Cyanosis: venous congestion, insufficient tissue oxygenation.
• Hyperemia: a typical sign of inflammation.
• Dystrophic changes (hair loss, skin thinning, peeling): indicate chronic circulatory insufficiency.

The physician also assesses pigmentation (insufficient in vitiligo or syphilitic leukoderma, excessive in melanoses and varicose veins) and the presence of local elements: fissures, erosions, ulcers, scabs, pustules, or blisters.

Special attention requires scars. When describing them, their localization, size, color (pigmented or not), and mobility (whether the scar is fused with the bone or underlying tissues) are indicated. Etiologically, scars may remain after vaccination, smallpox, syphilis, tuberculous lymphadenitis of the neck, trophic ulcers of the leg, or surgical operations.

Class and exam questions

What else to study on this topic

• Topography and palpation of the axes of the upper and lower extremities
• Differential diagnosis of types of skin pigmentation
• Types of local skin elements (ulcers, blisters, erosions) in surgery
• Determination of tumor mobility relative to underlying tissues

Other Topics in «CHAPTER 9. EXAMINATION OF THE SURGICAL PATIENT»

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.