SurgicalShort-CaseMadeEasy

 Always make sure both you and your patient are comfortable during clinical
examination

 ABPI is an obsolete test for acute ischaemic limb
 Running commentary

Don’t
 Rude to the patient
 Hurt the patient during examination (Eyes contact with the patient)
 If patient has "abdominal aortic aneurysm”, you are exempted to examine the

abdomen.
 Ask permission if you like to open the dressing

Discussion
 Investigations to confirm the diagnosis
 Investigations to assess the severity
 Classifications of limb ischaemic (Fontaine classification, Wifi scores)
 Immediate medical treatment for limb saving purpose
 Minimal invasive therapy: limb saving procedures
 Emergency embolectomy limb saving procedures
 Lifesaving procedures
 By-pass surgery

87

Module-9 Digital Rectal Examination & Proctoscopy

Indications for (Per-rectal examination & Proctoscopy)

Diagnostic indications:
 Chronic constipation, Unexplained anaemia, Unexplained bone pain, Unexplained
weight loss, Lumbar nerve root pain,
 Per rectal bleeding, diarrhoea (Change of bowel habit) (Haemorrhoids, Polyps,
Malignancy, Inflammatory bowel disease.etc)
 Upper GI bleeding
 To look for primary source of malignancy
 Fecal incontinence, Anal condyloma, Perianal lesions
 Patient with obstructive & irritative urinary symptoms
 Prostate diseases (Benign, malignant and infection)
 Rectal varices (Could be diagnosed by the proctoscopy only)
 Pelvic abscess, acute abdomen, Abdomen pelvic or spinal trauma
 Bimanual in gynaecological examination

Therapeutic indications: (Proctoscopy)
 Rubber band ligation of haemorrhoids
 Polypectomy

Approach to the Patient

Patient Preparation

Patient:
 Lying left lateral position (Modified Sim’s position) on bed/ hard coach with pillow,
flex the knee 90 degree and hip joint (Semi flex position) about 45-60 degree
 Alternative position (Lithotomy position for examination under anesthesia)
 Patient’s buttock should be placed 6-8cm beyond the edge of the bed
 Expose form the umbilical region to the mid-thigh/ (Cover the upper abdomen and
lower legs with blankets or Bedsheet)
 Place the arms at together in front of the patient's face
 Breathe slowly and relax
 Patient should empty the urinary bladder before the examination

Examiner:
 Hands should be warm, short nails
 Whole hand and forearm should be horizontal
 Sit or Stand (beside) the right side of the patient bed
 Eyes contact with the patient as possible
 Explain that you are going to examine the back passage of the patient inside the
abdomen

88

 It would be uncomfortable, but not painful. Request to co-operate and follow the
instruction

Material:
 Surgical gloves, alcohol hand rub, yellow bin

Fig. 106: Digital rectal examination

Examinations Steps
A. Building Rapport

 Greet the patient & introduce yourself
 Explain the patient what procedure is to be done
 Obtain permission
 Third party, Privacy
 Hand rubs before the examination (Put on the surgical gloves)
 Put the patient in correct position
 Adequate exposure and draping

B. Inspection
 General description of patient (Conscious level, pain/ distress, body built/cachexia,
pallor, jaundice, septic looking)
 Lift the buttock with your left hand and
 Inspect the obvious swellings, ulcers, openings fissures, old scar, fistula openings
 Inspect the discharge, soiling of mucus, faces, blood around the anus
 Inspect the anal skin tags and changes of anal skins

89

Fig. 107: Rectal prolapse
If there is a mass/ Swelling

 Describes, site, size, shape, condition of surrounding area & overlying skin etc.

Fig. 108: Fistula in ano
If there is an ulcer: (Acute fissure/ Chronic fissure)

 Describes, site, size, shape, edge, condition of surrounding area & overlying skin etc.
If there is/are and/the opening(s): (Fistula/ Sinus)

 Describes: site, size, numbers, raise or flat, edge, colour, condition of surrounding skin
area etc.
90

(Inspection)

Fig. 109: Prolapsed hemorrhoids

If there is a prolapsed hemorrhoid:
 Describes: severity in terms of circumference, any discharge, colour of prolapsed
mucosa etc.
 Finger invigilation test should be done to differentiate with prolapse rectum

If there is a sentinel pile:
 Describes: location in O’clock position, size and colour etc.

C. Per rectal examination
 Ask the patient whether there is any pain (if patient said it is painful (such as a case of
anal fissure), plan your examination under the anaesthesia)
 Inform your patient you are about to commence the digital examination
 Remind the patient to relax and take regular deep breaths
 After wearing surgical glove on adequate lubricants, place your index finger on the
sides of the anus gently (Usually at 6 0’clock position with modified sim’s position)
 Observe is there any anal spasm of not
 Once patient is relaxed, place your index finger to the center of the anus and give gentle
pressure toward the posterior (6 O’clock position) wall of the edge of the anal canal and
wait until the anal sphincter tone is relaxed
 Then introduce your index finger into the anal canal gently directed toward the patient’s
umbilicus

91

Fig. 110: Digital rectal examination
Per rectal examination

 Once you have introduced your finger to the end, ask patient to make a strain and check,
whether you can feel any mass during straining

 Then, ask patient to take a regular deep breath and rotate your index finger gently to
the 180 degrees in both directions (your forehand should be in pronation and supination
movements)

Fig. 111: Digital rectal examination
 Feel the mass, ulcers, mucosa mobility, recto-uterine / or/ vesicle pouch

92

Fig. 112: Digital rectal examination
 Feel the prostate in man: describe, size, symmetrical or asymmetrical, median groove,

consistency, upper border, mucosa mobility, lateral thickening (Winging of prostate).
 In female, you may feel the cervix as a firm mass (use bimanual examination to enquire

the: uterus and adnexal structures if it is indicated). (Make sure your patient emptied
the bladder before the examination or else, bladder will push the prostate downwards
and makes it feels bigger than usual.)

Fig. 113: Digital rectal examination
 Then you withdraw your finger gently until you reach to the internal sphincter area and

check the internal sphincter tone of the patient.
93

 Once your finger is out, check for the staining (feces, mucus, blood etc)
 If the procedure is done, make sure your patient is well, comfortable, and clean up the

lubricant around the patient’s anus with tissue paper.
 Discard the gloves and waste into the yellow bin

D. Proctoscopy

If you like to proceed with proctoscopy: (If it is indicated)
 Explain to the patient about the second procedure (Indications, Diagnostic &
Therapeutic)
 Prepare the light source (Unless you do not have built in light source in the proctoscope)
 Lubricate the proctoscope (outer sheath and obturator inside)
 Same method as digital examination: introduce the proctoscope gently into the anal
canal directed towards the patient’s umbilicus.
 Once it reached to the end, remove the obturator, and check inside (If there is soiling
of faces, clean it up with gauzes by sponge forceps)
 Check for any ulcer, mass, or mucosal abnormalities.
 Ask patient to make a strain and check, whether you can feel any mass during straining
 Then gradually withdrawal the proctoscope and observe any abnormalities under direct
vision
 If you wanted to check inside again, make sure you introduce obturator inside the stealth
of the proctoscope before you advance inside or else, you may traumatize the anal
mucosa.

If you find the hemorrhoids:
 Describe, size, location in O’ clock position, dentate line
 If it is indicated for rubber-band ligation, proceed with the procedure, and make sure
you fire the rubber band above the dentate line

“Proctoscopy”

If you find a mass above the dentate line:
 If it is indicated for the biopsy, take biopsy with biopsy forceps

If you find the prolapsed rectum:
 Describe, size, extend and colour of the mucosa
 Check the gap between prolapse bowel and anal margin (to differentiate the
intussusception and prolapse rectum)

Once you finished the procedure/ examination
 Clean up the patient’s anal area with gauzes/ tissue paper
 Make sure your patient is well (Not in giddiness, or palpitation)

Indications for EUA (Examination Under Anaesthesia)
1. Painful perianal lesion (e.g., Anal fissure, thromboses hemorrhoids, Perianal
abscess…etc)
2. Fistula in ano
3. To take biopsy of a lesion located below the dentate line

94

E. Offer systematic examinations if it is significant
 Examination of the abdomen
 Examination of the chest
 Vaginal examination
 (Request for full colonoscopy if it is indicated.)

F. Professional attitude

In the end of the examination:
 Clean up the patient’s anus with tissue paper
 Cover up the exposed part
 Thank the patient
 Hand wash after the examination

Dos
 Be gentle
 Eyes contact with the patient as possible
 Never forget to ask if there is an area of pain
 Always make sure both you and your patient are comfortable during clinical

examination
 Running commentary
 Consent is required for secondary examinations/ procedures

Don’t
 Rude to the patient
 Hurt the patient during examination (eyes contact with the patient)
 Disorganize steps of examination

Discussion
 Complete diagnosis with clinical findings which support the diagnosis
 Think about pre-procedure preparation post-procedure care for the colonoscopy
 Think about stand bowel preparation for endoscopy
 Think about differential diagnoses for discussion
 Think about severity of disease/ staging for discussion
 Formulate the investigations to confirm diagnosis and to assess the severity (or) staging

of disease
 Formulate the basic principles of management

95

REVIEWERS

Reviewer 1

Being a consultant surgeon in Yorkshire, United Kingdom after having being through a series
of professional examinations at Undergraduate medical school in Aberdeen, Scotland and at
Basic Surgical Training at West Of Scotland and Higher Surgical Training in Yorkshire
Deanery, I found a book with clear and concise instructions in handling surgical short cases,
not only during examinations but daily clinical practice, is essential in becoming a good
surgeon.

Having been involved in the local professional examinations at undergraduate and post
graduate master level during my work at University Malaya as a Professor in Surgery and
senior consultant surgeon, I can learn such a similar need in Malaysia. Not only that, this book
has also obtained valuable pictures of the pathology from Myanmar, where I visited as a
Visiting Professor and encountered the various pathologies that would be extremely useful to
our students in Malaysia and beyond.

Knowing Associate Professor Dr Yan Naing Soe from his work in University Tunku Abdul
Rahman and at Academy for Silent Mentor where he is our Pro Bono Tutor and Medical
Advisor, I found him a passionate teacher and clinician. From this collection of short cases,
you can clearly see that he has infused compassion and empathy in his approach to patients,
and this book aims to guide students in emulating this approach in their own respective practice.

Being an experienced surgeon and teacher at the bedside, he has laid down a methodological
approach with the foundation of clinical anatomy in relation to clinical signs and symptoms.
This ‘cookbook’ approach to the common surgical short cases is extremely valuable to
candidates of the professional examinations to ensure that not only they do well but do with a
sense of empathy. The success of a humane clinician will become apparent to those who
practise medicine with a clinical sense embedded with clarity and empathy.

By
Professor Chin Kin Fah
CEO, Clinical Training Centre, Academy For Silent Mentor, Cheras, Kuala Lumpur, Malaysia.

96

Reviewer 2

I have known Clinical Associate Professor Dr Yan Naing Soe since early 2000 when we
pursued RCSEd together.
I received the “Surgical Short-cases Made Easy” handbook from the Associate Professor Dr
Yan Naing Soe, Department of Surgery, Faculty of Medicine and Health Sciences, UTAR as a
reviewer as well as an editor.

I am sure it is an immensely helpful aid for the undergraduate trainees who are preparing for
the clinical and communication skills. It is packed with colour pictures, diagrams and tables
illustrating common surgical short cases.

This book is prepared as a module style format. Each of module commences with applied
anatomy, clinical crescendos followed by the generic formats for "Examination steps of various
systems, and then follows this with well-illustrated common cases, with matching notes that
will answer most of the questions the examiners will throw at you during the clinical part of
the exam. It is my sensible advice this book ensures that candidates can tick all of the examiners'
boxes when they sit the exam.

Generally speaking, you cannot pass the clinical without having practised, practised, practised,
but I recommend this book as one way of supplementing your preparation.

I would like to congratulate Associate Professor Dr Yan Naing Soe and all the contributors for
accomplishing a great job. The most beautiful part of the publication of this handbook is
“granting free access for the medical students”.

By
Dr Aung Lwin
Consultant Surgeon,
Ng Teng Fong General Hospital, Singapore.

Student reviewers of handbook:
Miss Wong Lee Chee
Miss Wong Yan Yu
Miss Soh Joe
Miss Goh June Lyn
Miss Daphne Wong Tze Yan

97

REFERENCES

Browse, N. L., Black, J., Burnand, K. G. and Thomas, W. E. G., 2005. Browse’s Introduction
to the Symptoms & Signs of Surgical Disease. 4th ed. London: CRC Press.
Cuschieri, A. and Hanna, G., 2015. Essential surgical practice: higher surgical training in
general surgery. 5th ed. Boca Raton, Florida: CRC Press.
National Comprehensive Cancer Network. 2022. Basal cell skin cancer: NCCN guidelines for
patients. [online] Available at: <https://www.nccn.org/patients/guidelines/content/PDF/basal-
cell-patient-guideline.pdf> [Accessed 24 March 2022].

98

INDEX

A Choledochal cyst...........................................................15
Cholelithiasis ..................................................................3
Abdomen .............................................................. 1, 2, 88 clavicular................................................. 1, 14, 15, 30, 43
Acute abdomen.......................................................... 1 Courvoisier’s Law...........................................................3
Nine regions .............................................................. 1 Cystic artery....................................................................3
Nine regions of abdomen........................................... 2 Cysts .............................................................................25

Abdominal .................................................... 1, 2, 5, 9, 20 D
Aberration..................................................................... 25
Abscess ......................................... 1, 3, 15, 25, 28, 88, 94 Dercum’s disease ..........................................................61
Amyloidosis.................................................................. 15 Dermoid cyst...........................................................60, 62
Anatomy ........................................................... 71, 96, 97 Digital rectal examination..................... 21, 88, 89, 92, 93
Distended urinary bladder.............................................18
Surgical Anatomy.............................. 1, 23, 33, 50, 79 Diverticulitis ...................................................................1
Anterior................................................... 2, 23, 34, 36, 50
Aortic aneurysm............................................ 1, 77, 86, 87 Meckel diverticulitis ..................................................1
Appendicitis.................................................................... 1 Dupuytren’s contracture................................................21
Appendicular .................................................................. 3
Auscultation.......................................... 20, 21, 43, 66, 86 E
Axillary hairs ................................................................ 21
Axillary lymph nodes.............................................. 23, 30 Empyema ........................................................................1
Enterocolitis .................................................................... 1
B Erythema ....................................................................... 21
Exophthalmos ................................................... 37, 38, 46
Biliary atresia................................................................ 15 Exteriorization ................................................................8
Biopsy......................................................... 25, 31, 66, 94
F
Core biopsy ............................................................. 25
Fine needle aspiration biopsy .................................. 25 Fascia ........................................................................2, 50
Sentinel nodes biopsy .............................................. 31 Femoral canal................................................................52
Stereotaxis biopsy.................................................... 25 Femoral triangle ................................................ 51, 52, 79
Wedge biopsy .......................................................... 25 Fluid thrills....................................................................16
Boas’s Sign ................................................................... 13 Focal nodular hyperplasia .............................................15
Breast........................................ 23, 25, 26, 27, 28, 32, 66
Buerger’s test ................................................................ 86 G

C Gallbladder ..................................................... 1, 3, 12, 15
Gastro-esophageal reflux ................................................1
Caecum ........................................................................... 3 Genitalia........................................................................ 21
Calcitonin...................................................................... 36 Goitre ......................................................................39, 40
Calot’s triangle ............................................................... 3 Goodsall’s rule................................................................3
Cancer -en- Cuirasse..................................................... 27 Gynecological .................................................................1
Carbuncle...................................................................... 68 Gynecomastia................................................................ 21
Carcinoid ........................................................................ 3
Carcinoma..................................................... 3, 25, 35, 54 H

Anaplastic carcinoma .............................................. 35 Head........................................ 3, 4, 11, 23, 26, 34, 46, 56
Follicular carcinoma ................................................ 35 Hemangiomas ...............................................................15
Medullary carcinoma............................................... 35 Hematological Malignancies.........................................15
Papillary carcinoma ................................................. 35 Hepatic adenoma...........................................................15
Carcinoma of Ovary........................................................ 3 Hepatic flaps .................................................................21
Carotid artery pulsation ................................................ 42 Hepatitis....................................................................1, 15
Cartilage ....................................................... 1, 12, 15, 43 Hepatomegaly ..................................................... 3, 15, 31
Cellulitis ....................................................................... 62 Hepatosplenomegaly ..................................................... 15
Cervical Lymphadenitis................................................ 62 Hernia ....................... 9, 14, 19, 20, 51, 52, 53, 55, 56, 58
Charcot’s triad ................................................................ 3
Cholangiocarcinoma ....................................................... 3 99
Cholangitis...................................................................... 1
Cholecystectomy............................................................. 7
Cholecystitis ................................................................... 1

Incisional hernia .......................................... 14, 19, 20 O
Inguinal hernia......................................................... 55
Umbilical hernia ...................................................... 19 Ovarian cysts...................................................................3
Hesselbach’s triangle .................................................... 50
Hiatus hernia................................................................... 3 P
Humerus ....................................................................... 23
Hypochondrial ................................................................ 1 Pain1, 3, 4, 5, 9, 11, 12, 13, 20, 21, 26, 28, 32, 36, 41, 48,
Hypochondrium ...................................................... 12, 18 54, 57, 58, 61, 62, 66, 68, 69, 73, 74, 76, 77, 80, 81,
83, 86, 88, 89, 91, 95
I Epigastric pain ...........................................................1
Left hypochondrial pain.............................................1
Infected urachal cyst ....................................................... 1 Left iliac fossa pain....................................................1
Inflammation .......................................................... 27, 57 Peri-umbilical pain ....................................................1
Inflammatory bowel disease ..................................... 3, 88 Right Hypochondrial pain..........................................1
Inguinal..................................1, 50, 51, 53, 56, 72, 76, 83 Right iliac fossa pain .................................................1
Intestinal obstruction................................................. 7, 53
Intestine .................................................................... 3, 20 Pancreatic pseudocyst .....................................................3
Intraperitoneal................................................................. 3 Pancreatitis...................................................................... 1
Ischaemic limb.................................................. 79, 80, 87 Peau-d’-orange .............................................................. 27
Pedunculated fibroid .......................................................3
K Pelvic .................................................................. 8, 73, 88
Percussion ............................................. 14, 16, 17, 18, 49
Kidney .......................................................................... 16 Peritoneum.................................................... 2, 11, 12, 13
Ectopic kidney........................................................... 3 Peritonitis................................................................11, 13
Phimosis........................................................................ 55
Koilonychia .................................................................. 21 Portal hypertension .......................................................15
Posterior aponeurosis ......................................................2
L Preperitoneal ...................................................................2
Psoas .........................................................................3, 13
Langerhans...................................................................... 4 Pyelonephritis .................................................................1
Leishmaniasis ............................................................... 15
Leukonychia ................................................................. 21 R
Linea alba ....................................................................... 2
Liver ................................................. 3, 12, 14, 15, 21, 66 Renal colic ......................................................................1
Liver cysts..................................................................... 15 Renal punch ............................................................18, 19
Lower limbs...................................................... 21, 73, 74
Lower lobe pneumonia ................................................... 1 S
Lymph nodes .................................................... 23, 34, 50
Lymphatic drainage of breast........................................ 24 Saint’s triad.....................................................................3
Lymphoma.......................................................... 3, 15, 35 Sarcoidosis .................................................................... 15
Lymphomas .................................................................. 66 Sebaceous cyst ........................................................60, 61
Secondary metastasis ....................................................15
M Shifting dullness ...........................................................17
Sign...5, 10, 11, 12, 13, 18, 19, 21, 35, 37, 38, 42, 46, 47,
Malaria.......................................................................... 15
Malignancy ............................ viii, 3, 5, 35, 39, 46, 48, 88 48, 49, 53, 57, 61, 63, 64, 65, 66, 82, 96
Mammography.............................................................. 25 Boas’s sign...............................................................11
Mastectomy ............................................................ 31, 32 Boas's sign ...............................................................12
Mesenteric adenitis ......................................................... 1 Chvostek’s sign........................................................47
Metabolic disease.......................................................... 15 Clinical signs ...........................................................11
Metastasis ................................................... 15, 35, 46, 57 Cullen’s sign..............................................................5
Muscles....................................... 2, 11, 23, 33, 47, 63, 71 Dunphy’s sign....................................................11, 13
Myocardial infarct .......................................................... 1 Grey Turner’s signs ...................................................5
Murphy’s sign....................................................11, 12
N Obturator sign ....................................................11, 13
Obvious clinical signs................................................5
Neck.........................14, 20, 25, 33, 34, 35, 36, 38, 41, 42 Pemberton’s sign .....................................................35
Psoas sign ................................................................11
Rovsing’s sign .........................................................11
Troisier’s sign ....................................................21, 66
Trousseau’s sign ................................................21, 47
Skin............................................... 2, 8, 36, 60, 75, 81, 82
Solitary thyroid nodule .................................................39
Spherocytosis ................................................................15

100

Spider naevi .................................................................. 21 Tumour ................................. 3, 15, 25, 27, 31, 57, 60, 73
Spleen ............................................................... 15, 16, 66 Carcinoid tumour.......................................................3
Splenic ...................................................................... 1, 15 Gastrointestinal stromal tumour.................................3
Stoma................................................................ 5, 7, 8, 13 Phyllodes tumour.....................................................25
Phyllodes Tumour....................................................27
Complications of stoma ............................................. 8 Transverse colon tumour ...........................................3
Stomach .............................................................. 3, 12, 18 Vascular tumour ......................................................15
Succussion splash ......................................................... 18
Supraclavicular ..................................... 21, 30, 31, 34, 66 U
Surgical scar ................................................................... 5
Systemic-Lupus-Erythematosus.................................... 15 Ulcer .1, 27, 29, 46, 62, 67, 68, 69, 73, 75, 76, 80, 83, 90,
94
T Gastric ulcer...............................................................1
Peptic ulcer ................................................................1
Testicular atrophy ......................................................... 21
Testis................................................................... 3, 21, 56 Umbilical hernia .............................................................1
Umbilicus............................................ 5, 7, 20, 51, 91, 94
Undescended testis .................................................. 54 Unilateral nipple retraction ...........................................27
Thoracic vertebrae ........................................................ 12 Ureteric colic...................................................................1
Tongue protrusion test ............................................ 35, 41
Trachea ............................................................. 35, 43, 49 V
Transillumination.......................................................... 63
Tremors............................................................. 35, 44, 45 Vein ....3, 5, 15, 27, 34, 52, 69, 71, 72, 73, 74, 75, 76, 77,
Tube................................................................ 5, 9, 40, 57 82, 86
Varicose veins ....................................... 71, 72, 73, 75
drainage tube ........................................................... 40
Drainage tube ............................................................ 5 Veno-occlusive disease .................................................15
T-tube ........................................................................ 9 Virchow’s triad ...............................................................3
Tubercles iliac crest ........................................................ 1
Tuberculosis.................................................................. 15
Tuberculous .................................................................... 3

101

Biography of Author

Dr Yan Naing Soe is a Clinical Associate Professor of Surgery / Head of
Department of Surgery, Faculty of Medicine and Health Science, Universiti
Tunku Abdul Rahman. He pursued his MBBS degree in 1993 (University of
Medicine -2, Myanmar) and he attained his Master degree in Surgery
(MMedSc) in 1999 (University of Medicine 1, Myanmar). He obtained his
MRCSEd, UK(General Surgery) in 2004. He is a registered specialist with
National Specialist Register, Academy of Medicine Malaysia as well as a
member of College of Surgeons Academy of Medicine Malaysia. His clinical
interest includes Endoscopy and Laparoscopic Surgery. He is also a Medical
Advisory Board Committee member of Academy for Silent Mentor Clinical
Training Centre, Cheras, Kuala Lumpur.

Surgical Short-Case Made Easy:
A Handbook