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41 - Examination of flaps and grafts
- from Section 10 - Plastic surgery
-
- By Edmund Fitzgerald, St Andrew's Centre, Yezen Sheena, Health Education East of England, Cambridge, UK, Henk Giele, Oxford University
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 362-366
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Summary
Checklist
WIPER
Physiological parameters
General
• Note any scars, deformities or skin lesions. Offer to inspect the whole body.
Inspection
• Identify any flaps and grafts, and describe any scars present (see Chapter 40, Examination of scars).
• Comment on the location.
• Flap:
• site and size
• type of flap: local, regional or distant
• phase of healing: well-healed, immaturity of scar, adequacy of outcome
• check donor sites or exposure scars
• Graft:
• site, size and colour match of graft
• type of graft:
– pattern of scarring: split-thickness skin graft (STSG) or full-thickness skin graft (FTSG)
– cobblestone or crocodile skin appearance (derived from a meshed graft)
• healing: graft take as a percentage
• bed of flap: muscle flap/native muscle/fat
• Check common graft donor sites:
• upper thighs for STSG
• inner upper arms, supraclavicular fossa, retroauricular, groins for FTSG
Palpation
• Consistency: thickness, pliability, contour
• Vascular supply: colour, capillary refill
• Neurology: sensation
• Base:
• firm (recurrent disease or scarring)
• fluctuant (seroma or haematoma)
To complete the examination…
• Inspect for donor sites and any other scars/skin lesions.
• Offer to palpate regional lymphatic drainage sites if previous cancer excisions.
Examination notes
What is the system for inspecting flaps and grafts?
S-T-H-D:
Site
Type
Healing
Donor site
What is the difference between a flap and graft?
• A skin graft consists of skin tissue taken from one area of the body and transferred to another, being dependent on the recipient site for blood and nutrients.
• A flap consists of tissue taken from one area of the body and transferred to another, bringing with it its own source of blood and nutrients.
What are the different types of grafts?
Split-thickness skin graft (STSG)
• Split-thickness skin grafts consist of epidermis and a variable amount of dermis.
• STSGs are able to resurface larger areas than full-thickness grafts.
37 - Global neurological examination
- from Section 9 - Neurosurgery
-
- By Harry Bulstrode, University College London, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Diederik O. Bulters, Honorary Senior Clinical Lecturer, Wessex Neurological Centre, Southampton, UK
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
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- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 319-331
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39 - Examination of skin lesions and lumps
- from Section 10 - Plastic surgery
-
- By Edmund Fitzgerald, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK, O'connor Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Petrut Gogalniceanu, University of Medicine and Pharmacy, Henk Giele, Oxford University Hospitals
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 353-358
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Summary
Checklist
WIPER
• Good light source. Lesion and loco-regional lymph nodes exposed.
Physiological parameters
• Ask: ‘Where is the lesion?’
• Ask: ‘Is the lesion painful?’
System
• S-E-I-S (Site, External, Internal, Surroundings)
Skin type
• Fitzpatrick classification of skin type
Site
• Location of lesion
• Number of lesions
External features
• Size (in cm)
• Shape:
• smooth or irregular edge
• flat or raised profile
• Surface:
• skin: intact or ulcerated skin, skin adnexae
• colour/pigmentation and telangiectasia
• colour distribution: regular vs. irregular
• discharge: blood, pus, lymph
• Scars from previous surgery (skin lesions or lymphadenectomy)
Internal
• Consistency: soft, hard
• Content: gas (crepitus), fluid (fluctuant and transilluminable), solid (nontransilluminable)
• Dynamic interaction: pulsatile, reducible, indentable, compressible
• Mobility and attachment to surrounding structures (above, below and laterally)
• Percussion: dull or resonant (gas, fluid, solid)
• Auscultation: bruits, bowel sounds
Surroundings
• Assess surrounding skin: normal or satellite lesions.
• Palpate for local, regional, general lymphadenopathy.
• Assess nerves: local and distal sensory and motor functions.
• Assess vascular supply of lesion: capillary refill time and pulses.
• Palpate liver for an irregular edge or enlargement and vertebral spine for tenderness if concerned about metastatic deposits.
Examination notes
Tip
The examination of a lump is very poorly done in general, due to a lack of a systematic or anatomical way of approaching the lesion. Palpation in particular needs to be structured as described above in order to avoid redundant gestures.
What is the system for examining a skin lump?
S-E-I-S:
Skin (type) and Site (inspection)
External features (inspection)
Internal features (inspection and palpation)
Surroundings: skin, local, regional or distal lymph nodes (inspection, palpation and movement)
Tip
Beware the melanoma patient with a prosthetic eye or ear.
What are the principal questions in assessing a skin lesion?
• Where is the lesion located on the body?
• What does the lesion look like externally?
• What is inside the lesion?
• What is the anatomical plane of the lesion?
40 - Examination of scars
- from Section 10 - Plastic surgery
-
- By Edmund Fitzgerald O'connor, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Henk Giele, Oxford University Hospitals
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 359-361
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Summary
Checklist
WIPER
Physiological parameters
Look
• Anatomy: Site, Orientation, Length, Colour, Contracture
• Healing status: fresh, healing, healed, mature
• Healing method: primary or secondary intention
• Pathological scarring: hypertrophic or keloid changes, scar widening or stretching
• Infection: sinuses, fistulas, granulation or discharge
• Signs of surgical correction (e.g. z-plasty)
Feel
• Tenderness
• Thickness, pliability
• Adherence
• Evidence of malignant occurrence or recurrence
Move
• Mobility of scar
• Mobility and laxity of surrounding skin
• Associated functional impairment (test related muscles, joints and nerves)
To complete the examination…
• Assess regional lymph nodes.
• Obtain formal function assessment by occupational therapist/physiotherapist as required.
Examination notes
How do wounds heal?
Skin scarring is the normal and inevitable outcome of cutaneous wound healing. Wound healing follows a sequence of overlapping phases: haemostasis, inflammation, proliferation and remodelling.
What factor must be considered on inspection?
• Cause: Consider underlying medical comorbidities that led to the scar, but never assume the surgical procedure if this information has not been given.
• Colour: An assessment of the colour of the scar may indicate its age. Wound healing has defined sequential yet overlapping stages within which the scar will change in colour. As a scar passes from the proliferative phase through to remodelling and finally into a mature scar so its colour will decrease in red pigmentation. A variegated pink scar is younger than a homogeneous white scar.
• Location: The position of the scar indicates potential functional complications. If the scar is over a joint there is a risk of contractures causing decreased range of movement. Assess for underlying neurovascular function and deficits following surgery or injury: for example, periorbital scars may be associated with ectropion directly from cicatricial healing, or weakness due to damage to the temporal branch of the facial nerve (CN VII), or a sensory loss due to trigeminal nerve (CN V1) injuries.
9 - Examination of the breast
- from Section 3 - Breast surgery
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- By Petrut Gogalniceanu, London Postgraduate School of Surgery, London, UK, Yezen Sheena, Health Education East of England, Cambridge, UK, Michael Douek, Consultant Breast Surgeon, King's College London
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 89-98
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Summary
Checklist
WIPER
• A chaperone will help the patient get changed into an examination gown in a private area.
• The patient is positioned sitting on the edge of the bed with hands resting on hips.
• The breasts are exposed only when the examination begins.
Physiological parameters
General
• Weight loss
• Radiotherapy tattoos or Hickman line scar (for chemotherapy)
• Donor site scars: TRAM or DIEP flap (lower abdomen), LD flap (back) or other scars (e.g. gluteal or transverse myocutaneous gracilis)
• Bra: prosthetic or cosmetic inserts suggestive of breast asymmetry, bra cup size
Inspection
• Chest wall/spine/shoulder: symmetry/deformities (crucial to apparent breast appearance)
• Breast: volume, symmetry, shape, projection, chest wall position
• Nipples: deviation, retraction, inversion, discharge, Paget's disease, eczema
• Skin: scars, mammary fistulas, erythema
• Soft tissues: lumps, skin dimpling, peau d'orange, cancer en cuirasse, ulceration
• Haagensen manoeuvre: press arms on hips, lift hands behind head, slowly lower arms
• Axillae: masses, SLNB or ANC scars
• Supraclavicular fossae: swelling/masses
• Arms: lymphoedema (comment on any compression garment), muscle wasting
Palpation
• Breast: masses, tenderness:
•four breast quadrants (upper/lower, outer/inner)
•nipple and retroareolar tissues
•axillary tail of Spence
• Nipple: discharge
• Axilla: lymphadenopathy (five sites per side), accessory breasts
• Lateral chest wall: port sites for breast expander implants
To complete the examination…
• Neck/supraclavicular fossae: lymphadenopathy
• Spine: tenderness
• Abdomen: hepatomegaly
• Chest: pleural effusions
Examination notes
How are breast lumps assessed?
Any new breast lump requires triple assessment. Symptomatic patients should be assessed in a one-stop breast clinic.
What does the triple assessment involve?
Clinical: examination by a surgeon
Imaging: breast ultrasound (women under 40 years) or mammography (women 40 years or older)
Histology: fine-needle aspiration (FNA) or core biopsy
Each is scored 1–5 (1 = low, 5 = very high risk).
38 - Focal neurological examination
- from Section 9 - Neurosurgery
-
- By Harry Bulstrode, University College London, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Diederik O. Bulters, Honorary Senior Clinical Lecturer, Wessex Neurological Centre, Southampton, UK
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 332-352
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Summary
Neurological examination is traditionally divided into examination of the cranial nerves and examination of the peripheral nervous system. In fact the two routines are complementary, and serve a common primary goal: to localise pathology within the nervous system, central and peripheral. Together with an impression of the type of lesion, derived primarily from the history, this localising information is central to correct interpretation of subsequent cross-sectional imaging.
Examination of the cranial nerves
You may need to select appropriate components of the following examination routines according to the clinical scenarios and guidance provided by examiners. This is a test of frontal lobe function.
Checklist
CN I (olfactory nerve)
• Not routinely tested
CN II (optic nerve)
• Acuity: each eye individually
• Fields: four quadrants to confrontation
• Reflexes: accommodation; direct and consensual light reflex
• Ophthalmoscopy: visualise the disc, exclude papilloedema
CN III, CN IV, CN VI (oculomotor, trochlear, abducens nerves)
• Ask patient to report any double vision during testing.
• Instruct patient to keep the head still.
• Ask patient to follow finger with eyes and report any double vision.
• Move finger to all extremes of gaze in an H-shape, to confirm normal upgaze/downgaze in both eyes, in abduction and adduction.
CN V (trigeminal nerve)
• Assess fine touch sensation in the three divisions:
• ophthalmic (Va) over temple
• maxillary (Vb) over cheek
• mandibular (Vc) over angle of mandible
• Confirm masseter/temporalis contraction on clenching teeth.
• Elicit corneal reflex and jaw jerk.
CN VII (facial nerve)
• Ask patient to:
• raise eyebrows
• close eyes tightly
• puff out cheeks
• show teeth
CN VIII (vestibulocochlear nerve)
• Test recognition of whispered speech in each ear individually.
• Weber's and Rinne's tests.
CN IX (glossopharyngeal nerve)
• Offer to test gag reflex.
• Prompt the patient to cough, looking for a strong cough.
• Prompt the patient to swallow, observing for symmetry.
42 - Examination of burns
- from Section 10 - Plastic surgery
-
- By Yezen Sheena, Health Education East of England, Cambridge, UK, Edmund Fitzgerald, St Andrew's Centre, Petrut Gogalniceanu, London Postgraduate School of Surgery, Henk Giele, Oxford University
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 367-370
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Summary
Acute burns
Checklist
WIPER
Physiological parameters
General
• Resuscitate patient.
• ITU support: airway, hydration, analgesia and antibiotics.
• Comment on dressings already applied.
Look
• Site of the burn
• Airway compromise risk factors: singed nasal hairs, perioral burns, blistered palate, swelling of tongue or naso-oral mucosa, hoarse voice due to laryngooedema, swollen uvula
• Percentage of total body surface area (TBSA) burnt
• Circumferential burns to chest or limbs
• Depth of burn:
• superficial (epidermal)
• superficial partial-thickness (superficial dermal)
• deep partial-thickness (deep dermal)
• full-thickness
• Assess any structure(s) involved at the base of the burn.
Feel
• Sensation/tenderness
• Capillary refill time in burn, peripheral and centrally
• Moist or dry burn
• Assess peripheral pulses
• Assess chest movements if any circumferential burns
• Identify compartment syndrome in circumferential limb burns
Move
• Movement of underlying joints
Old burns
Checklist
WIPER
Physiological parameters
General
• Tracheostomy scar
• Fitted pressure garments/splints
Look
• Site affected by the burn
• Extent of burn
• Burn and donor sites: graft/flap healing status, colour, contour, contracture, cosmetic result
Feel
• Burn and donor sites for healing result: thickness scars, texture, sensation, tenderness, pliability
Move
• Assess contraction of scars around joints, testing ROM.
• Assess functional impairment of local structures.
To complete the examination…
• Assess neurovascular status of loco-regional tissue involved.
Examination notes
What is a burn?
A burn is the coagulative necrosis of tissue due to a thermal, chemical, electrical, friction or radiation insult.
What are the guidelines for the management of burns?
Advanced Trauma Life Support (ATLS)
Emergency Management of Severe Burns (EMSB) principles
One must accurately assess the burn size and depth, as this will determine further specialist management.
43 - Examination of the hands
- from Section 10 - Plastic surgery
-
- By Yezen Sheena, Health Education East of England, Cambridge, UK, Edmund Fitzgerald, St Andrew's Centre, Petrut Gogalniceanu, London Postgraduate School of Surgery, Henk Giele, Oxford University
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 371-382
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- Chapter
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Summary
Checklist
WIPER
• Hands on a pillow on the patient's lap
Physiological parameters
• Ask if there is any pain
Systemic observations
• Aids/splints
• Ears: gouty tophi
• Face: scleroderma, acromegaly, hypothyroidism
• Elbow extensor surfaces: rheumatoid nodules, psoriasis plaques
Look
• Skin: scars, palmar erythema, finger pulp infarcts, cyanosis, nail changes
• Soft tissues: muscle wasting, swelling around tendons
• Bone: Heberden's and Bouchard's nodes (OA), square wrists and finger deformities in RA (z-thumb, swan neck and ulnar drift deformities), joint subluxations
Feel
• Skin: temperature, tenderness
• Soft tissues:
• nodules, cords and fascial contractures (Dupuytren's)
• joints: tenderness, swelling, mucous cysts, ganglions
• tendons: boggy swelling (tenosynovitis), ruptures
• Bone: bone tenderness, crepitus, instability
Vascular
• Radial and ulnar pulses
• Capillary refill time
• Allen's test (see Chapter 26, Arterial examination of the upper limbs)
Sensory nerves
• Median: palmar thenar eminence and radial 3.5 fingers
• Ulnar: palmar hypothenar eminence and ulnar 1.5 digits
• Radial: dorsum of hand first web space
Motor nerves
• Median:
• thumb abduction (‘palm up, thumb vertical’)
• thumb and index finger: ‘OK sign’
• Ulnar:
• interossei PAD/DAB: cross fingers test
• adductor pollicis: Froment's (thumb-paper test)
• abductor digiti minimi: little fingers pressed against each other
• Radial:
• extensor pollicis longus: ‘flat palm down on table, lift thumb’
• extensor digitorum communis: extension of four digits
Move
• Test active then passive ROM with a view to identifying neurological, tendon or joint stiffness, crepitus, triggering, instability.
• Assess MRC power grading for each muscle or composite movement as required (see Chapter 38, Focal neurological examination).
Ask patient to make a fist, then to extend all the fingers.