CSL5 Examination OF Swelling & Ulcer PDF

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clinical skill...

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CSL EXAMINA EXAMINATION TION OF SWELLING & LUMP Site

 Description of site of swelling

Size

 Can used anatomical landmarks  cm x cm

Shape

 Correspond to shape of swelling  Use 3D dimensional  Eg : - globular - spherical

Surface

- oblong  The surface of swellling  Eg : - regular - nodular - lobulations - appearance like erythme

Margin or border

- dilated veins  Outer structure of swelling  Eg : - regular - irregular - well defined

Consistency

- ill defined  The feel of the swelling  Eg : - soft - firm

Tenderness

- hard --> malignancy  Cannot be ask

Mobility

 Observe the patient reaction or discomfort during examination  Need to be examine in 2 planes  Examine : - side to side - upward & downward  Result : - mobile if movable in both planes SPECIAL FEATURES

Fluctuation test :

1. Used 2 hands to doing this test 2. Left hand - observing one Right hand - examining one 3. Need to be test in 2 planes to check mobility of swelling 4. Result : - positive : detected movable in both planes at right angle to another - indicate prresence of fluid in the swelling

Slip sign test : 1. Used 1 finger to press down the edge of swelling 2. Observe the sensation of swelling slipping away 3. Result : - positive : swelling slipping away - indicate swelling in subcutaneous plane

Indentation sign or sign of moulding : 1. Pressing the tip of finger at the center on top of swelling 2. Then, move the finger & observe the present of finger expression on the swelling 3. Then, it slowly fills up return to normal shape 4. Result : - positive : the finger tip shape present on swelling & slowly fiils up to normal shape - indicate sebaceous cyst

Pinching test : 1. Pinch the skin over the swelling using 2 finger (index and middle finger) 2. Result : - pinch the skin --> not attached to skin - cannot pinch the skin --> origin from skin Noted : breast swelling *skin attachment or involved --> higher stage of breast cancer Transillumination test : 1. Place pen torch direct opposite with swelling 2. Used 6 to 8 inches long tube with 2.5 to 3cm diameter 3. Check either the swelling is translucent or opaque 4. Result : - translucent --> contains serous fluid Eg : hydrocele , cystic hygroma

Pulsation of swelling : 1. Place 1 finger of 2 hand each on pulsating swelling perpendicular to one another 2. Result : - transmitted --> 2 fingers rising & falling directly above swelling --> indicate : swelling not pulsating but pushed by pulsating swelling below it - expansile --> 2 fingers rising & distance both finger at same time --> indicate : aneurysm from vessel

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ABDOMINAL MASS EXAMINATION _____________________________________________________________________________ Introduction : 1. Introduce yourself to patient 2. Ask for chaperone 3. Ask consent (verbal) 4. Position of patient :  Supine with one pillow under head 5. Ask patient either any pain anywhere 6. Sanitize hand

Inspection : 1. Description :  Site  Scars over the swelling  Size  Shape  Surface  Movement with respiration  Any pulsating movement  Over skin condition

Palpation : 1. Head raising test :  Check mass in intraabdominal or arising from anterior abdominal wall  Procedure : - place right hand on mass - ask patient to raise the head  Result : - intra abdominal mass --> the mass less apparent

2. Check tenderness :  Palpate the mass & check any discomfort or pain  Check temperature & compare with surrounding normal area

3. Conformation :

 Check size, shape, surface on palpation

4. Identification of margin :  Check the swelling either the margin is regular or irregular

5. Check consistency :  Soft, firm or hard

6. Check the swelling can be get above or below  Based on position of swelling  Ribcage --> cannot move above but can move below  Central abdomen --> can move both above & below  Pelvic --> cannot move below but can move forward

7. Does it move with respiration  Ask patient to take a breath  Observe the swelling movable or stay

8. Is it mobile  Check using fluctuation test 9. Present in cough impulse  Ask patient to cough  Observe the swelling either more visible or not  Check present of hernia

10. Pulsatility & expansility  Using pulsating of swelling test

11. Balloted  Palpate sither the swelling is balloted

Percussion :  Do percussion to assess the boundary of mass

 Percuss from outward to inward of the swelling - from resonant to dull from different directions

Auscultation :  Auscultate mass to check for aneurysm

Finally : - palpate the supra-clavicular lymph nodes - the left one is known as Virchow’s node - lymphatic spread of cancer will reach that lymph node

_____________________________________________________________________________ LEG ULCER EXAMINATION _____________________________________________________________________________ Introduction :  Exposed whole lower limbs  Ask patient any pain  Observe the etiology of ulcer - arterial - venous - neuropathic - mixed

Inspection :  Inspect between toes, pressure points, heel, sole & malleoli  Inspect amputations & gangrene  Inspect surgical scars at leg & groin  Examination : - Site : goiter area (venous), pressure points (arterial) - Shape : regular or irregular (serpigenous) - Size : length cm x width cm - Margin : discolouration due to haemosiderin deposition firm or tender - Edge : sloping, punched out, undermined, everted (Marjolin’s ulcer-squamous cell cancer) - Floor : discharge – serous, serosanguinous, purulent - Base (Bed) : covered by healthy or unhealthy granulation tissue - covered by slough necrotic tissue - visible underlying structures maybe (tendon, muscle, or bone)

Palpation :  Find out etiology of ulcer  Perform full vascular examination of lower limbs - venous ulcer  Perform full vascular examination of lower limbs including ABPI & pulse - arterial ulcer  Perform full vascular examination with full neurological examination of lower limbs - neuropathic / diabetic ulcer

Complete examination :  Blood test - exclude infection, diabetes & hypercholesteremia  Duplex scan - to examine arterial & venous system  ABPI  Arterial angiogram...