Primary adrenocortical insufficiency
Tonic pupil syndrome - associated with diminished or absent tendon jerks - common in young women.
In Wilm's tumor - after resection if no recurrence of tumor for a period of (child's age at presentation) + 9 months - child considered cured.
Allen Brown's criteria
For diagnosis of Raynaud's phenomenon
Anderson Hynes operation
Dysjunction pyeloplasty for repair of idiopathic P-U junction obstruction.
Aphorism of Mayo, Charles
"A Meckel's diverticulum is frequently suspected, often sought, and rarely found."
Aphorism of Moynihan
"A gallstone is a tombstone to the memory of the organism within it."
Aphorism of Moynihan - 2
"The stomach is the mother of the GIT. With any disease of the tract, like a mother weeps, so is there vomiting."
Arnold Chiari malformation
Herniation of Clar tonsils thro foramen magnum - lower CN palsies+Clar limb signs+UMN signs in legs
Microdochectomy - done for persistent nipple discharge from 1 or few ducts.
Deltopectoral flap - for repair of cheek defects like in Ca cheek - operated, or in cancrum oris.
Band of Ladd
In arrested rotation of midgut & subsequent volvulus neonatorum - peritoneal band from the caecum which is on left side to right side - obstructs the 2nd part of duodenum.
Oculo-pharyngeal muscular dystrophy.
Extra-serous approach - extraperitoneal or extra pleural - used esp to drain abscess - avoids contamination of the cavity.
JG cell hyperplasia with very high Plasma Renin activity (PRA) + hypokalemia + 2ndary hyperaldosteronism + short stature.
Upward movement of umbilicus on attempted neck raise / SLR - seen with weakness of the lower AAW muscles.
Similar to Duchenne's - milder - onset late teens - limb weakness appears much later - may survive up to middle age and beyond.
Familial spastic paraplegia with or without optic atrophy.
Basilar migraine - occurs in younger individuals - involves mostly brainstem signs in the aura & headache - diplopia, dysarthria, deafness, blindness, bilateral parasthesias, bilateral paresis, etc.
Symptom index scale for hypothyroidism
Bishop - Koop operation
For meconium ileus - ileocolostomy
Boari's flap operation
For repair of lower end of ureter in case of fibrosis, surgical excision, or accidental damage - bladder wall fashioned into a tube like extension.
For palpation of spleen - ask patient to jump up & down 8-10 times then palpate in right lateral position - previously non-palpable spleen may be felt.
Boerema - Crile operation
For portal hypertension - trans-thoracic ligation of bleeding varices
Full thickness post emetic tears in esophagus - lead to mediastinitis, hemothorax, cardio-respiratory embarrassment.
Posterior part of the 3rd frontal gyrus of the dominant lobe
One form of chronic osteomyelitis
Thrombo-angitis obliterans (TAO) - distal symmetrical panvasculitis of medium & small blood vessels.
Meralgia parasthetica - entrapment of the femoral N at the inguinal ligament - pain & parasthesia on antero-lateral aspect of thigh.
Bushke - Lowenstein tumor
Giant condyloma acuminatum - locally invasive & may recur after resection - bt has no malignant cells.
Cabana's lymph node
Superomedial group of superficial inguinal lymph nodes - sentinel for glans - inguinal dissection in Ca penis only if these are positive.
Rheumatoid arthritis + coal worker's pneumoconiosis / PMF
To diff betn abdominal wall tenderness & intra-abd tenderness. Patient asked to sit half-way up, tenderness disappears in intra-abd cause. AAW tenderness in sprain, myositis, nerve entrapment.
In pellagra - around neck - rash only in sun exposed areas.
Celsius features of inflammation
Dolor (pain), Rubor (redness), Calor (raised local temperature), Tumor (swelling), Functio laesa (loss of function)
For cerebellar involvement - dysarthria + nystagmus + intention tremors
Pain + Jaundice + Fever with rigors - for acute cholangitis
Childs - Phillip's plication
Transmesenteric plication - modification of Noble's plication operation for multiple adhesions.
1st cardiac transplant
For 'latent' tetany - spasm of facial muscles on tapping branches of facial N as they leave the parotid gland.
CJD - Creutzfeldt - Jacob disease
Commonly presents with psychiatric (severe depression) & sensory (dys/paresthesias) symptoms, later develops dementia, FNDs (especially cerebellar), invol movts (esp myoclonus) & finally akinetic mutism.
CJD - familial form
Occurs with mutation at the polymorphic codon 129 of the PrP gene - affects younger age groups, & has a longer course than the sporadic form of the disease.
CJD - variant form
Cause of British beef scandal - infection occurred in the 1980's - affects younger individuals, more sensory symptoms, longer course of disease, upgaze palsy, absence of typical periodic EEG changes.
Courian Sax grading
For clubbing - suspected, slight, average, severe
Syndrome of multiple hamartomas
Venous hum at umbilicus with dilated Vv on AAW.
Discoloration of umbilical area d.t. hemoperitoneum - ruptured ectopic, trauma, acute h'gic pancreatitis.
Stress ulcer in stomach - in response to severe burns.
In raised ICT - Hypertension + Bradycardia + Bradypnea
Obesity is associated with abdominal striae (d.t. protein catabolic state) & hirsutism (d.t. associated sex hormone excess).
Stress ulcer in stomach - in response to major CNS trauma
Emptiness in the RIF - seen in ileo-colic intussusception
Rub skin with blunt end of a pen - palpable wheal develops in 1-2 min - seen in systemic mastocytosis proliferation of mast cells with excess histamine release.
For rectal prolapse - plication of musculature to form a ring with excision & repair of redundant mucosa
Dennis Browne urethroplasty
Used in hypospadias - as 2nd stage surgery after excision of the chordee done about 2-3 months before.
Pre-tibial myxedema + Exophthalmos + Clubbing - seen in thyrotoxicosis - clubbing is called thyroid acropachy.
Intermittent hydronephrosis with diuretic spells - d.t. excessively mobile kidney which causes intermittent kinking of the ureter - with intermittent release of the obstruction.
Interrupted aortic arch, Fallot's, Truncus arteriosus + Thymic hypoplasia / aplasia (with immune dysfunction) + Parathyroid hypoplasia / aplasia + ear abnormalities
For appendicectomy - lateral incision extending on both sides of McBurney's point
Margins for inguinal block dissection - Superiorly inguinal ligament, laterally down from ASIS for 20 cm, medially down from pubic tubercle for 15 cm, inferiorly joining inferior ends of these 2 lines.
Post - AMI pericarditis - causes a localised pericarditis with friction rub - develops 3-4 days after the AMI - resolves spontaneously.
Duchenne's muscular dystrophy
Meryon's disease - X-linked recessive - manifests in early teens - patients usually die by age 20.
Hydrocele - en - bisac - one part of the sac is in the scrotum while the other is in the canal, in the abdomen, etc.
EDS Type I
EDS - Gravis type - with severe joint hypermobility, skin laxity, bruising, & bleeding manifestations.
EDS Type II
EDS - Mitis type milder
EDS Type III
Benign familial joint hypermobility
EDS Type IV
Aortic - ecchymotic form
EDS Type IX
Cutis laxa; Menke's steely hair syndrome; associated with copper metabolism disturbance
EDS Type VI
EDS Type VII
Arthrochalosis congenita multiplex
EDS Type VIII
Ellis van Crevald syndrome
Chondro-ectodermal dysplasia - Chondrodysplasia + ectodermal dysplasia + polydactyly + congenital heart disease.
X-linked dystrophy - deficiency of emerin - early onset contractures of Achille's tendon, elbows, humeral & peroneal muscle weakness and contractures, and serious cardiac conduction defects.
Erb Duchenne palsy
C5,6 affected - upper cord lesion - hand cannot be flexed & pronated - lies limp by the side - "porter's tip" position, sensory loss over lateral side of UL & thumb & index finger.
Erb's march of motor paralysis
In progressive cord compression - especially extra-dural / medullary - 1st involves ipsilateral UL, then ipsi LL, then contra-lateral LL, then contra-lateral UL - d.t. arrangements of fibers in the cortico-spinal tracts - antero-laterally arranged.
Multiple defects in proximal tubule - glycosuria, AA-uria, Phosphaturia, Uricosuria
Splenomegaly + neutropenia (pancytopenia with immune deficit) + rheumatoid arthritis
Ferriman - Gallway score
For hirsutism - assesses hair growth at nine specific androgen dependent sites - each gets score 0(no terminal hair) to 4 (frankly virile) (min 4 , max 36) - >8 score = hirsutism.
For clubbing - according to angle between nail & nail bed
Perihepatitis d.t. gonococcal infection - asso with P.I.D.
Foster Kennedy syndrome
With frontal lobe lesion - optic atrophy in ipsilateral eye with papilledema in opposite eye.
Fowler Stephen's operation
For undescended testis - if cord cannot be lengthened d.t. testicular A stretching - A. ligated & testis brought down - collateral supply from A to vas & cremasteric A will suffice.
Formed by endothelial proliferation + perivascular reaction --- seen in Rickettsial infection - these org multiply in the capillary endothelial cells - intracellular parasites.
Cardiomyopathy, conduction defects + Ataxia + dysarthria + degeneration of dorsal column tracts
Combined spino-cerebellar degeneration with concomitant peripheral neuropathy, with myocardial degeneration with progressive myocardial fibrosis.
Obesity + lethargy + genital hypoplasia + amenorrhea - without abdominal striae or hirsutism (difference from Cushing's syndrome).
Oblique for liver, adrenal, & pancreas
Done for sacro-iliac subluxation.
Lesion of the dominant parietal lobe - ALF - Agraphia, Acalculia, Left-right disorientation, Finger agnosia
Gilles de la Tourette syndrome
Complex tics with coprolalia & copropraxia - starts in childhood - persists into adulthood - treated with DA antagonists / anti-psychotics.
Glasgow Coma Scale
Devised by Jaenett & Teasdale in 1974.
In polymyositis & dermatomyositis - heliotrope (lilac colored) discoloration of the knuckles.
Cone excision of all major ducts - done for persistent nipple discharge from all or many ducts. Defect closed by purse-string sutures.
Excision of affected bowel + proximal colostomy + distal end closed & kept in situ.
Henoch Schonlein purpura
Autoimmune IgA mediated condition - common in children - classic triad of rash (infex) + abdominal pain / renal involvement + arthritis - may cause renal failure.
For reduction of anterior dislocation of shoulder - surgeon applies traction with hands & counter-traction with foot in the axilla.
In peritonitis - d.t. shock.
Holstein Lewis syndrome
Radial N palsy 2ndary to # shaft of humerus.
Holt Oram syndrome
ASD + Skeletal defects of UL + clavicle dysgenesis
Miosis + Partial ptosis + Anhydrosis - seen d.t. disturbance of the sympathetic supply to eye anywhere in its course.
Cluster headaches - common in adult males - occur in clusters - unilateral, associated with lacrimation, nasal stuffiness - ppted by stress, alcohol, smoking, nitrates.
Arthritis of rheumatic fever - form which involves the distal smaller joints & leaves residual scarring
Jack - knife position
Prone, with hips flexed over a break in the table - used for rectal surgery & lumbar laminectomy.
For Ca penis - see notes.
Hypereosinophilic syndrome - with atopic dermatitis, high IgE levels, recurrent pyodermas, & decreased chemotaxis of mononuclear cells.
Congenital def of GnRH with anosmia. Leads to hypogonadotrophic hygonadism.
Kantor's string sign
On small bowel enema in Crohn's disease at the ileum.
Dextrocardia + situs inversus + sinusitis + bronchiectasis + sterility (ciliary dysfunction)
Serum-sickness like illness caused in acute schistosomiasis when the adult worms start producing eggs - fever, Lnpathy, urticaria, arthritis,edema.
Mucocutaneous LN syndrome - High fever + skin/mucous membrane affection + Extremity involvement + Rash + conjunctivitis + cervical Lnpathy --- acute, self limiting - like collagen disease - in children
In head injury - cause of 2ndary brain injury - space occupying effect causes herniation - opposite cerebral peduncle pressed against the tentorium - pyramidal tract affection on the same side of the body.
Protrusion of pharyngeal mucosa between thyropharyngeus & cricopharyngeus.
For cardiac pump failure - 4 groups - prognosis (mortality) corresponds to this clinical staging especially in AMI.
Klumke Dejerine palsy
C8, T1 affected - lower cord lesion - intrinsic hand muscle weakness & wasting, sensory loss over inner side, Horner's syndrome.
Incision, Vein (thyroid), Kocherisation, Kocher's test (for thyroid - tracheomalacia), Forceps, Method for reduction of anterior dislocation of shoulder, lateral approach to the elbow - in orthopaedic surgery.
Ileostomy with continent intra-abdominal pouch
Commonly follows Wernicke's encephalopathy - severe amnesia is the main feature, with confabulation - amnesia may be antegrade or retrograde.
1st person to use an esophagoscope
Acidotic breathing - rapid deep breathing
Paradoxical rise in JVP on inspiration - seen in pericardial effusion, constrictive pericarditis, COPDs
Abdominal operation for rectal prolapse - passed through rectus sheath
Transverse right sided in iliac region - for appendix & caecum - more cosmetic - may be used in females
For disc prolapse - pain on passive raising of the straight leg (SLR)
Laurence Moon Biedl syndrome
Variable congenital heart defects + retinitis pigmentosa + polydactyly + obesity + microcephaly + MR
X linked recessive defect of HGPRTase deficiency - gout asso. with CNS changes like choreoathetosis, spasticity, mental deficit, and compulsive self mutilation.
On neck flexion - electric shock like sensations in the dermatome of affected segment part of spinal cord - seen in multiple sclerosis / radiation myelopathy.
Li Fraumeni syndrome
Hereditary cancer syndrome - deletion of p53 - also called SBLA - Sarcoma, Breast, Brain, Lung, Larynx, Leukemia, Adrenal tumor syndrome.
Seen in rachitic bones - radioluscent transverse lines in the XR, usually on the concave side of the bone not extending to the opposite cortex. Most commonly seen in adult osteomalacia, & renal osteodystrophy.
Angle between nail & nail bed - usually 168 degrees - obliterated in clubbing
Lyme disease - 3 stages
Early localised (erythema at bite site), early dissem (flu, cardiac - blocks, neurological - meningism, enceph), late persistent (arthritis, chronic neurological, cutaneous)
Lynch syndrome 1
Hereditary non-polyposis colorectal Ca (HNPCC) - autosomal dominant inheritance - multiple primaries - rt sided - also Ca uterus & ovary are common.
Multiple enchondromatosis (Ollier's disease) + multiple soft tissue haemangiomas - may be cause of clubbing.
Partial thickness esophageal post emetic tears - lead to upper GI bleed & hematemesis
"Tree root" sign on XR - angiography in vascular occlusion d.t. lymphatics.
Grid Iron type of incision.
Forehead flap - based on superficial temporal A.
Partial persistence of the omphalo-mesenteric duct at its junction with the ileum.
Ascites, pleural effusion asso with ovarian fibroma.
Cystic glandular hyperplasia of stomach mucosa - leads to protein losing enteropathy & hematemesis.
Millin - Walker's operation
For portal hypertension - trans - thoracic porta-systemic disconnection - by transection & reanastomosis of esophagus.
Injection treatment for piles
Thrombophlebitis of superficial veins of breast and chest wall, may involve upper limb.
Morgan - Milligan operation
For hemorrhoids - "open" technique of hemorrhoidectomy
For intestinal polyps - broad groups are - (1) Hamartomatous, (2) Metaplastic, (3) Inflammatory, (4) Neoplastic - benign & malignant.
Pain + Vomiting + Fever - for acute appendicitis
Same as Murphy's sign - Naunyn described it 13 yrs before Murphy did.
Hyperpigmentation with pituitary tumor. Occurs d.t. high ACTH d.t. treatment of pituitary Cushing's with bilateral adrenalectomy.
To treat Peyronie's disease
Noble's plication operation
For multiple adhesions
Pulmonary valve dysplasia or hypertrophic cardiomyopathy + Cryptorchidism + pectus excavatum + webbed neck
Mesenteric adenitis occurring in teenage girls - attacks of central abdominal pain with circum oral pallor.
For undescended testis - testis brought down into scrotum & fixed by inserting it across septum into other hemi-scrotum.
For portal hypertension - trans-abdominal ligation of bleeding varices
Idiopathic retroperitoneal fibrosis
Osler Weber Rendu disease
Hereditary Hemorrhagic telangiectasia
To detect pseudoHT - caused d.t. calcification of the Aa - Feel for the radial A with cuff pressure >SBP - if palpable - means the A is calcified & gives false high BP.
Tender nodules formed in the pulps of fingers & in the thenar & hypothenar eminences - seen in IE
1st cardiac transplant in India - at AIIMS
Paget - Schroetter's syndrome
Effort - vein thrombosis - see notes on thoracic outlet syndrome.
Loss of vertical gaze associated with refractory nystagmus on convergence + pseudo - Argyll Robertson pupils present - causes - pinealoma, MS, vascular lesions.
Restorative procto-colectomy with ileo-anal pouch
Paul - Mikulicz operation
Resection of affected intestine + both ends brought out side by side flush together. Subsequent closure of stoma by crushing septum in between the 2 ends & closing roof of stoma.
Corpora cavernosa involved - multiple fibrotic plaques - deformed penis - treated by Nesbitt's operation - sutures put in opposite side of contractures to straighten the penis.
Transverse infra-umbilical - for pelvic organs.
Ascites d.t. constrictive pericarditis
Billroth II gastrectomy
Post coital test - other names
Sim's test, Huhner's test. Modification - Miller Kurzrok test - cervical mucus & sperms taken onto slide & penetration tested under microscope.
Ankle # - bimalleolar type
Pott's puffy tumour
Osteomyelitis of the skull bones - commonly after an open # - causes an inflammatory of the scalp.
TB spine - commonly presents as paraplegia - destroys the body AND IV discs (which are spared in 2ndaries to spine) - causes vertebral body collapse & paravertebral abscess - bird nest sign on AP XR.
In torsion testis - aggravation of the pain on elevating the testis - differentiates it from acute epididymo-orchitis.
Angina at rest or occurring in specific patterns - 'start-up' angina, 'decubitus' angina, 'nocturnal' angina
Pseudo Meig's syndrome
Ascites, pleural effusion asso with uterine fibroid.
Ramsay - Hunt syndrome
Herpes zoster oticus (vesicles in the canal) + LMN facial palsy + Regional adenopathy + Vertigo + anesthesia over anterior 2/3 of the corresponding hemitongue.
Charcot's triad (pain + fever + jaundice) + CNS excitatory / depressive effects + septic shock - from operating on an infected biliary system.
Conjunctivitis + Urethritis + Arthritis + Oral ulcers + Periarteritis - associated with HLA B27.
Riley Day syndrome
Familial dysautonomia syndrome - manifests in babies.
Abdominal operation for rectal prolapse - attached to sacral promontory by Teflon sling
XR sign - ossification of iliac apophysis - used as a measure of skeletal maturity.
Tonic pupils with altered knee jerks, with hypohidrosis
Roussy Levy syndrome
Mild ataxia + pes cavus + arreflexia + peroneal muscle atrophy + thickened nerves (in some)
For polycystic kidney disease - "de-capping" of cysts - to relieve pressure atrophy of renal parenchyma & reduce discomfort.
Rutherford Morrison's pouch
Right hepatorenal pouch - most dependent part of peritoneal cavity in supine position.
Chronic cholecystitis (d.t. GB stones), Diverticulitis, Hiatus hernia - all present with dyspepsia.
For lumbar flexion testing - keep 2 fingers over the spine, one 5 cm below a point on the spine at level of the dimple, & other 10 cm above it - ask patient to bend forwards - if length between fingers increases
For diagnosis of T.A.O. - Buerger's disease.
Silber Kelly operation
For undescended testis - the cord is lengthened after ligating testicular A with micro-vascular anastomosis with the inferior epigastric A.
Alkali denaturation test to detect foetal Hb.
Hereditary cancer syndrome - with association of pheochromocytoma & medullary Ca thyroid - same as MEN type 2a
Chronic paroxysmal hemicrania - like cluster headches - except more common in females - responds to indomethacin treatment.
Somogyi phenomenon - DM
Post - hypoglycemic - hyperglycemia occurs in early morning after bout of hypoglycemia at about 3 a.m. Treatment - decrease the bed-time insulin dose.
Undescended / Elevated scapula.
Reversible hepatic cellular dysfunction in RCC
Steele Richardson Olszewski S
Progressive supranuclear palsy - loss of vertical & later horizontal gaze which is associated with extrapyramidal signs, neck rigidity & dementia. Reflex eye movements on head movements + (supra nuc)
Stein Levinthal syndrome
PCOD --- Amenorrhoea + Sterility + Hirsutism + Obesity (ASHO) --- causes secondary amenorrhea in a young woman - treated with Clomiphene --- 50-100 mg for 1st 5 days of month for 6 months.
Evening confusion followed by agitation - seen in late stages of Parkinsonism - the fluctuating stage.
In coarctation of aorta - bruits heard over the back - d.t. opening up of the periscapular anastomosis, & d.t. increased blood flow through the IC Aa.
Supramalleolar amputation of foot - Heel pad rotated anteriorly over sawn off ends of tibia & fibula.
For portal hypertension - trans - abdominal porta-systemic disconnection - by transection & reanastomosis of proximal part of stomach.
Umbilicus position in relation to xiphisternum & pubic symphysis - to differentiate between ascites & pelvic lump e.g. ovarian cyst.
Thoracic outlet syndrome d.t. Pancoast tumor
Post-ictal paralysis - D/D for a hemorrhagic stroke
Tolosa Hunt syndrome
Superior orbital fissure syndrome - painful lesins of the V1, III, IV, VI CN.
For varicose veins - sapheno-femoral disconnection with flush ligation of the saphenous stump on the femoral V.
Trendelenburg's operation - 2
For pulmonary embolism - pulmonary embolectomy
Supine + head low position - facilitates pelvic surgery by causing intestines to gravitate upwards.
In varicose veins - 2 parts - 1st for leg perforators, 2nd for sapheno-femoral junction
Isolated enlargement of Virchow's nodes - seen in late stages of abdominal & pelvic malignancies.
Migratory throbophlebitis - seen commonly with advanced intra-abdominal malignancies. Observed by Trousseau in himself d.t. his Ca stomach d.t. which he died.
Trousseau's sign - tetany
For 'latent' tetany - carpopedal spasm on occluding arm blood supply with BP cuff inflated.
Van Nuys classification
Pathological classification for DCIS - based on nuclear grading and presence or absence of necrosis (comedo pattern).
Van Nuys scoring
For prognosis in DCIS treated with excision - uses the Van Nuys classification, tumor size, and the width of the margin. Score can be 3,4 (minimal risk), 5,6,7 (intermed risk) or 8,9 (high risk).
VSD, Vertebral anomalies + Anal atresia + Tracheo-Esophageal fistula + Radial anomalies, Renal anomalies
On the buttocks - at the level of the posterior superior iliac spine - the sacro-iliac joints lie just below it.
Left supraclavicular nodes - enlarged in Troisier's sign
To explain causes of coagulation - 1) Changes in vessel wall 2) Changes in blood constituents 3) Changes in flow of blood.
Volkmann's contracture - causes
Compartment syndrome, Arterial damage, Tight POP cast, prolonged tourniquet application, hyperflexion.
Von Economo's disease
Encephalitis lethargica - post influenzal encephalitis - one of the D/D's for Parkinsonism.
Von Recklinghausen's disease
Neurofibromatosis, osteitis fibrosa cystica
For portal hypertension - devascularization of stomach varices - ligation of left gastric vein.
Warren's operation - 2
For portal hypertension - distal spleno-renal shunt
Symptom index for hyperthyroidism
Abdominal operation for rectal prolapse - attached to sacrum by polyvinyl sponge
Werner Zoege von Manteuffel
First to advocate use of sterilised rubber gloves for surgery in 1897. Till then surgeons mostly operated with bare hands !!!
Multiple endocrine neoplasia - type 1
Posterior part of the 1st temporal gyrus of the dominant lobe
Ataxia + ophthalmoplegia + confusion - may progress to Korsakoff's psychosis - treated as medical emergency with 50-100 mg Thiamine IV & only then other glucose infusions.
Rare disease with diarrhea, arthralgia, CNS signs, and skin pigmentation. Caused by intestinal infection by Trophyrema whipelli - has multisystemic manifestations - prolonged treatment with Tetra - 1 year or more.
Partial pancreatectomy with duodenectomy.
Diagnostic criteria for Insulinoma - Attacks in fasting or exercising state, BSL
SMA syndrome - occlusion - leads to MVA or mesenteric ischemia - pain in abdomen after meals.
First described typhoid fever in 1892
Supravalvular AS + peripheral pulmonary stenosis + 'elfin' facies + hoarse voice + mental deficiency
Winwarter - Buerger disease
Cerebral form of T.A.O.
For hernia - the 3 finger test - ring finger over saphenous opening, middle finger over the superficial ring & index over the deep ring - patient asked to cough.