Clinical examination of swelling

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Clinical examination of swelling

  1. 1. POWER POINTCLINICS
  2. 2. DR.M.RAVI CHANDRA,M.S(G.S)ASST. PROF. OF SURGERYRIMS SRIKAKULAM
  3. 3. INSPECTION 1. SITE- EXACT ANATOMICAL LOCATION IMPORTANT AS SOME SWELLINGS OCCUR IN A TYPICAL POSITION WHICH IS DIAGNOSTIC EXAMPLES  POST AURICULAR DERMOID-BEHIND EAR  EXTERNAL ANGULAR DERMOID –LATERAL END OF EYE BROW  MENINGOCELE- OVER THE BACK IN MIDLINE
  4. 4. EXTERNAL ANGULAR DERMOID*Image via Bing
  5. 5. EXTERNAL ANGULAR DERMOID*Image via Bing
  6. 6. *Image via Bing
  7. 7. SUB MANDIBULAR DERMOID*Image by 12498905@N02 via Flickr
  8. 8. *Image by 48276084@N00 via Flickr
  9. 9. DERMOID CYST OF SCALP*Image via Bing
  10. 10. DERMOID CYST IN MID LINE*Image via Bing
  11. 11. ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW*Image via Bing
  12. 12. *Image via Bing
  13. 13. MENINGOCELE*Image via Bing
  14. 14. HUMAN TAIL?*Image via Bing
  15. 15. 2.NUMBER USUALLY SINGLE , SOME TIMES MULTIPLE MULTIPLE EXAMPLES  MULTIPLE NEUROFIBROMATOSIS(VON RECK LING HAUSENS DISEASE)  MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)  DIAPHYSEAL ACLASIS  HYDRADENITIS SUPPURATIVA  MULTIPLE LYMPHOGLANDULAR SWELLINGS
  16. 16. *Image via Bing
  17. 17. *Image via Bing
  18. 18. MULTIPLE LIPAMATOSIS*Image via Bing
  19. 19. HYDREDENITIS SUPPURATIVA OF AXILLA *Image via Bing
  20. 20. *Image via Bing
  21. 21. *Image via Bing
  22. 22. EXTEXNSIVE SCARRING UNDER THE ARMS DUE TO HYDREDENITIS SUPPURATIVA*Image via Bing
  23. 23. 3.SHAPE SPHERICAL OVOID KIDNEY /BEAN SHAPED/RENIFORM IRREGULAR
  24. 24. 4.SIZE
  25. 25. 5.SURFACE COLOUR SPECIAL CHARACTER OF SURFACE OVERLYING SKIN
  26. 26. A)COLOUR ARTERIAL HAEMANGIOMA – BRIGHT RED VENOUS HAEMANGIOMA— PURPLE MALIGNANT MELANOMA- BLACK BENIGN NAEVUS – BLACK RANULA –BLUE
  27. 27. CAPILLARY HAEMANGIOMA OVER FORE HEAD *Image via Bing
  28. 28. BENIGN NEVUS
  29. 29. BENIGN NEVUS *Image via Bing
  30. 30. HERIDITARY DYSPLASTIC NAEVUS SYNDROME *Image via Bing
  31. 31. *Image via Bing
  32. 32. MALIGNANT MELANOMA*Image via Bing
  33. 33. *Image via Bing
  34. 34. MALIGNANT MELANOMA OF FOOT*Image via Bing
  35. 35. RANULA*Image via Bing
  36. 36. *Image via Bing
  37. 37. RANULA OF RIGHT SUBLINGUAL*Image via Bing
  38. 38. b)Character of surface TWO CHARACTERISTIC SURFACES ON INSPECTION  CAULIFLOWER SURFACE – SQUAMOUS CELL CARCINOMA  FILIFORM BRANCHED SURFACE – PAPILLOMA (IRREGULAR NUMEROUS BRANCHED SURFACE)
  39. 39. SQUAMOUS CELL CARCINOMA*Image via Bing
  40. 40. *Image via Bing
  41. 41. SCC OF TONGUE*Image via Bing
  42. 42. FILIFORM SURFACE OF PAPILLOMA*Image via Bing
  43. 43. INDONESIAN TREE MAN*Image via Bing H.P.V. AFFECTING HANDS &LEGS
  44. 44. c)Skin over lying swelling TENSE , SHINY WITH PROMINENT VEINS – SARCOMA RED &EDEMATOUS – INFLAMMATORY BLACK PUNCTUM – SEBACEOUS CYST PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS SCAR  PREVIOUS OPERATION(REGULAR SCAR WITH SUTURE MARKS)  INJURY(REGULAR SCAR)  SUPPURATION(PUCKERED ,BROAD &IRREGULAR)  PEAU - D ORANGE APPEARANCE(MAINLY IN CA. BREAST) ULCERS
  45. 45. ABSCESS*Image via Bing
  46. 46. ABDOMINAL WALL ABSCESS*Image via Bing
  47. 47. NASAL ABSCESS*Image via Bing
  48. 48. INFECTED SEBACEOUS CYST WITH PUNCTUM*Image via Bing
  49. 49. SOFT TISSUE SARCOMA*Image via Bing
  50. 50. *Image by 88761406@N00 via Flickr
  51. 51. *Image via Bing
  52. 52. 6.VISIBLE PULSATIONS PULSATION  A MOVEMENT OR INCREASE IN SIZE SYNCHRONOUS WITH EACH HEART BEAT  2 TYPES  EXPANSILE PULSATIONS – SWELLINGS ARISING FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID BODY TUMOUR  TRANSIMITTED PULSATIONS – SWELLINGS CLOSE TO ARTERIES  REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION
  53. 53. 7.VISIBLE COUGH IMPULSE PERFORMED WHEN SWELLING IS OVER ABDOMEN,CHEST,SPINAL CANAL OR CRANIUM COUGH IMPULSE  VISIBLE INCREASE IN THE SIZE OF SWELLING SYNCHRONOUS WITH COUGH POSITIVE IN SWELLINGS COMMUNICATING WITH ABDOMEN,THORACIC CAVITY,SPINAL CANAL OR CRANIAL CAVITY
  54. 54. POSITIVE COUGH IMPULSE HERNIA MENINGOCELE VARICOCELE SAPHENA VARIX  IN CHILDREN CRYING ACTS AS COUGHING
  55. 55. 8.VISIBLE PERISTALYSIS OBSERVED IN ABDOMINAL LUMPS AND INGUINAL SWELLINGS CONGENITAL HYPERTROPHIC PYLORIC STENOSIS – VISIBLE GASTRIC PERISTALYSIS INGUINAL HERNIAS (ENTEROCELE) INTESTINAL PERISTALYSIS LUMPS DUE TO INTESTINAL MALIGNANCY PERISTALYSIS IS SEEN
  56. 56. 9.MOVEMENT WITHRESPIRATION SEEN IN ABDOMINAL LUMPS SWELLINGS ARISING FROM  STOMACH  LIVER  SPLEEN  GALLBLADDER  HEPATIC FLEXURE OF COLON  SPLENIC FLEXURE OF COLON  RENAL LUMP THOUGH NOT IN CONTACT WITH DIAPHRAGM ,MOVES WITH RESPIRATION
  57. 57. 10.Movement with deglutition IN CASE OF NECK SWELLINGS  SWELLINGS MOVING WITH DEGLUTITION  THYROID SWELLING  THYROGLOSSAL CYST  THYROGLOSSAL FISTULA  SUBHYOID BURSA  PRE/PARA TRACHEAL LYMPH NODES  EXTRINSIC CARCINOMA OF LARYNX
  58. 58. WHY THYROID MOVES UP WITH DEGLUTITION? THYROID IS ENCLOSED IN PRETRACHEAL FASCIA PTF ATTACHES TO THYROID &CRICOID CARTILAGES(BERRY’S LIGAMENT) SUPERIOR CONSTRICTOR MUSCLE CONTRACTION DURING DEGLUTITION THESE CARTILAGES MOVE UP ALONG WITH THESE THYROID MOVES UP
  59. 59. 11)MOVEMENT WITH TONGUE PROTRUSION IN CASE OF MID LINE NECK SWELLINGS EG:THYROGLOSSAL CYST &FISTULA WHY?  ATTACHED TO FORAMEN CAECUM OF TONGUE
  60. 60. 12)PRESSURE EFFECTS WHEN SWELLING IS PRESENT ON LIMBS  AN AXILLARY SWELLING WITH LIMB EDEMA – LYMPHNODAL SWELLING  PARESIS – PRESSURE ON NERVES  WASTING OF MUSCLES OF DISTAL LIMB- TRAUMATIC SWELLING(WASTING DUE TO NON-USE/INJURY TO NERVES)  SWELLING IN NECK WITH VENOUS ENGORGEMENT(RETROSTERNAL EXTENSION)
  61. 61. PALPATION DEFINITE CLUE TO DIAGNOSIS METHODICAL,FOLLOW DEFINITE ORDER BE GENTLE SHOULD NOT HURT THE PT.
  62. 62. 1.TEMPERATURE IT IS AN ABSOLUTE STANDARD PRACTICE TO TEST FOR TEMP FIRST-WHY? BEST FELT BY BACK OF THE HAND-WHY? INCREASED IN  INFLAMMATORY SWELLING  WELL VASCULARISED TUMOURS- SARCOMA
  63. 63. 2.TENDERNESS PAIN DUE TO PRESSURE EXERTED OVER THE SWELLING IS TENDERNESS PALPATE GENTLY OVER ALL THE AREA IT IS A SIGN FEATURE OF  INFLAMMATORY SWELLINGS  SWELLING RELATED TO NERVES -NEUROFIBROMA
  64. 64. 3.SIZE& SHAPE CONFIRM VERTICAL & HORIZONTAL DIMENSIONS NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION
  65. 65. 4.SURFACE WITH PALMAR SURFACE  SMOOTH –CYSTIC SWELLINGS  LOBULARWITH SMOOTH BUMPS-LIPOMA  NODULAR –MULTI NODULAR GOITRE/MATTED LYMPH NODES  IRREGULAR - CARCINOMA
  66. 66. SMOOTH SURFACE OF A SEBACEOUS CYST*Image via Bing
  67. 67. *Image via Bing
  68. 68. M..N.G. WITH NODULAR SURFACE
  69. 69. 5.EDGE 1)WELL DEFINED & REGULAR – BENIGN NEOPLASMS 2)WELL DEFINED & IRREGULAR – MALIGNANT NEOPLASM 3)ILLDEFINED &DIFFUSE –INFLAMMATORY SWELLINGS
  70. 70. ABSCESS WITH ILL DEFINED MARGINS*Image by 9085776@N08 via Flickr
  71. 71. LIPOMA WOTH WELL DEFINED MARGINS*Image by 72310117@N07 via Flickr
  72. 72. LARGE LIPOMA WITH WELL DEFINED MARGINS *Image by 78523246@N00 via Flickr
  73. 73. *Image by 78523246@N00 via Flickr
  74. 74. IRREGULAR BORDERS IN CARCINOMA BREAST*Image via Bing
  75. 75. SLIP SIGN *Image via Bing TO DEFFERENTIATE BETWEEN LIPOMA AND CYSTIC SWELLING(BOTH HAVE WELL DEFINED ,REGULAR BORDERS) WHEN EDGE OF A SWELLING IS PALPATED WITH A FINGER ,IF IT SLIPS UNDER THE FINGER,. DOES NOT YIELD TO IT , IT IS A LIPOMA,IF IT YIELDS TO FINGER IS A CYST
  76. 76. 6.CONSISTENCY SOFT – LIPOMA CYSTIC- CYSTS &CHRONIC ABSCESSES FIRM –FIBROMA HARD BUT YIELDING-CHONDROMA BONY HARD-OSTEOMA STONY HARD- CARCINOMA VARIABLE CONSISTENCY- MALIGNANCY
  77. 77. HOW TO ASSESS CONSISTENCY SOFT – EAR LOBULE,ALAE OF NOSE FIRM- TIP OF NOSE,UN CONTRACTED MUSCLE HARD -BRIDGE OF NOSE,CONTRACTED MUSCLE
  78. 78. SIGN OF MOULDING ORINDENTATION LOOK FOR THIS SIGN IN SOFT &CYSTIC SWELLINGS  PRESS A FINGER INTO SWELLING FOR 1-2 MTS AND RELEASE IT IF SWELLING REMAINS INDENTED IT INDICATES PRESENCE OF PULTACEOUS MATERIAL(PUTTY LIKE) SEEN IN  1.SEBACYOUS CYST  2.DERMOID CYST  3.COLONIC MASS WITH FAECAL MATTER
  79. 79. PAGET’S TEST DONE FOR SMALL SWELLINGS TO KNOW THE CONSISTENCY(CYSTIC/SOLID) THE CENTRE AND PERIPHERIES ARE PALPATED WITH INDEX FINGER  CYSTIC SWELLING FEELS SOFTER AT CENTRE THAN PARIPHERY  SOLID SWELLING FEELS FIRMER ATCENTRE THAN PERIPHERY
  80. 80. SPECIAL TESTS DONE IN CASE OF SOFT/CYSTIC SWELLING  7.FLUCTUATION  8.TRANSILLUMINATION  9.COUGH IMPULSE  10.REDUCIBILITY  11.COMPRESSIBILITY IN SOLID SWELLINGS DIRECTLY PROCEED TO TEST FOR RELATION TO OTHER STRUCTURES
  81. 81. 7.FLUCTUATION TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER IMPLIES PRSENCE OF FLUID IN THE SWELLING
  82. 82. HOW TO ELICIT FLUCTUATION? IF THE SWELLING IS MOBILE FIRST FIX IT OR ASK THE ASST. TO HOLD IT KEEP 2 INDEX FINGERS ON OPPOSITE POLES WHEN ONE FINGER IS PRESSED THE FINGER AT OPPOSITE END FEELS THE IMPULSE & PASSIVELY LIFTED UP REPEAT THE MANUVERE IN A PLANE AT RIGHT ANGLES TO THE 1ST ONE IF IMPULSE IS FELT IN BOTH PLANES IT IS A POSITIVE FLUCTUATION TEST
  83. 83. LAW BEHIND FLUCTUATION! PASCAL’S LAW  PRESSURE EXERTED TOA FLUID IS TRANSMITTED EQUALLY IN ALL THE DIRECTIONS *Image via Bing
  84. 84. PRINCIPLES WHILE DOING FLUCTUATIONTEST ALWAYS PERFORM IN 2 DIRECTIONS AT RIGHT ANGLES TO EACH OTHER TWO FINGERS SHOULD BE KEPT AS FAR APART AS POSSIBLE FREELY MOBILE SWELLINGS SHOULD BE FIXED FIRST(AS IN HYDROCELE) SMALL SWELLINGS –WATCHING FINGER & DISPLACING FINGER VERY LARGE SWELLINGS MORE THAN ONE FINGFR SHOLD BE USED
  85. 85. PSEUDO FLUCTUATION A FALSE SENSE OF FLUCTUATION FELT IN LARGE SOFT SWELLINGS CONTAINING NO FLUID SEEN IN  LARGE LIPOMA  MYXOMA  SOFT FIBROMA  VASCULAR SARCOMA FAIL TO EXPAND IN OTHER PARTS OF A SWELLING LIKE A TRUE FLUCTUANT SWELLING
  86. 86. CROSS FLUCTUATION FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER SEEN IN  COMPOUND PALMAR GANGLION  PSOAS ABSCESS  PLUNGING RANULA
  87. 87. 8.TRANSILLUMINATION DEMONSTRATION OF TRANSMISSION OF LIGHT THROUGH A SWELLING POSITIVE IN SWELLINGS CONTAINING CLEAR FLUID AND THIN TRANSPARENT WALLS NO TRANSILLUMINATION IF WALL IS THICK, OR TURBID FLUID IS PRESENT(BLOOD,PUS, LYMPH) DARK ROOM , TRANSILLUMINOSCOPE
  88. 88. BRILLIANTLY TRANSILLUMINANT SWELLINGS 1.CYSTIC HYGROMA 2.EPIDIDYMAL CYST 3.MENINGOCELE WITH THIN SKIN 4.RANULA 5.CONGENITAL HYDROCELE
  89. 89. 9.COUGH IMPULSE PERFORMED IN SWELLINGS LIKELY TO BE IN CONTACT WITH ABDOMINAL ,CRANIAL ,SPINAL OR CHEST CAVITY SWELLING IS HELD WITH FINGERS AND PATIENT IS ASKED TO COUGH IF THE SWELLING BECOMES TENSE OR INCREASES IN SIZE IT IS POSITIVE COUGH IMPULSE IN CHILDREN CRYING ACTS AS COUGH
  90. 90. SWELLINGS WITH POSITIVE COUGH IMPULSE IN CONTINUITY WITH ABD. CAVITY  HERNIA  ILIO-PSOAS ABSCSS  LUMBAR ABSCESS IN CONTINUITY WITH PLEURAL CAVITY  EMPYEMA NECESSITANS IN CONTINUITY WITH SPINAL /CRANIAL CAVITY  SPINAL/CRANIAL MENINGOCELE
  91. 91. 10.REDUCIBILITY INDICATION SAME AS FOR COUGH IMPULSE PATIENT IS ASKED TO RELAX SWELLING IS COMPRESSED FROM ALL THE SIDES UNIFORMLY REDUCIBLE SWELLINGS DECREASESIN SIZE OR COMLETELY DISAPPEAR
  92. 92. REDUCIBLE SWELLINGS 1.HERNIA 2.MENINGOCELE 3.VARICOCELE 4.SAPHENA VARIX  A REDUCIBLE SWELLING ONCE REDUCED REAPPEARS ONLY BY STRAINING,COUGHING, OR FORCE OF GRAVITY AS IT INVOLVES DISPLACEMENT OF VISCERS TO AN ADJOINING CAVITY
  93. 93. 11.COMPRESSIBILITY WHEN PRESSURE IS APPLIED TO A SWELLING IT DECREASES IN SIZE AND WHEN PRESSURE IS RELEASED SWELLING REGAINS ITS SIZE ITSELF WITH OUT ANY EXTERNAL FACTORLIKE STRAINING OR COUGHING CHARECTARISTIC SIGN OF VASCULAR HAEMANGIOMA
  94. 94. 12.PULSATILITY WHEN FINGER IS PLACED OVER A PULSATILE SWELLING IT RAISESWITH EACH BEAT TO TYPES OF PULSATIONS  TRANSMITTED PULSATIONS- SEEN IN SWELLINGS PRESENT NEAR AN ARTERY  EX:CA STOMACH LUMP NEAR ABD.AORTA  EXPANSILE PULSATIONS-SEEN IN SWELLINGS ARISING FROM ARTERIES  EX:AORTIC ANEURYSM
  95. 95. HOW TO DIFFERENTIATE? TWO FINGERS ARE PLACED OVER THE SWELLING AND FINGER MOVEMENTS ARE NOTED TRANSMITTED PULSATIONS – FINGERS ARE SIMPLY LIFTED UP EXPANSILE PULSATIONS- FINGERS ARE LIFTED UP AND MOVE APART
  96. 96. IN AN ABDOMINAL LUMP? KNEE ELBOW POSITION  WHEN KEPT IN KNEE ELBOW POSITION  PULSATIONS DISAPPEAR – TRANSMITTED PULSATIONS  PULSATIONS PERSIST –EXPANSILE PULSATIONS
  97. 97. 13.FIXITY TO SKIN SKIN PINCHED OVER DIFFERENT PARTS OF THE SWELLING -CANNOT BE PINCHED IF FIXED TO SKIN SKIN IS MADE TO MOVE OVER THE SWELLING- THE SKIN WILL NOT MOVE IF IT IS FIXED TO SKIN SWELLINGS ARISING FROM SKIN ARE FIXED TO SKIN EX:SEBACEOUS CYST , PAPILLOMA , EPITHELIOMA
  98. 98. 14.RELATION TO SURROUNDING STRUCTURES 1)SUBCUTANEOUS TISSUE  SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT ADHERENT TO SKIN OR UNDERLYING MUSCLE  LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN SOME PLACES – DUE PRESENCE OF FIBROUS SEPTA 2)DEEP FASCIA  SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS MOBILE AS SUBCUTANEOUS SWELLINGS  IT IS DIFFICULT MAKE OUT FIXATION TO DEEP FASCIA AS DEEP FASCIA CANNOT BE MADE TAUT  EVEN IF TUMOUR IS ATTACHED TO UNDERLYING DEEP FASCIA &MUSCLE TUMOUR CAN BE MOVED SIDEWAYS
  99. 99. 3)RELATION TO MUSCLE RELATION SHIP TO MUSCLE IS KNOWN BY THROWING THE CONCERNED MUSCLE INTO CONTRACTION  TUMOURS IN SUB CUTANEOUS TISSUE- BECOME MORE PROMINENT &REMAIN MOBILE  TUMOURS ARISING FROM MUSCLE / INCORPORATED IN MUSCLE-FIXED&IMMOBILE  TUMORS DEEP TO MUSCLE –LESS PROMINENT, OR DISAPPEARS,DIFFICULT TO PALPATE
  100. 100. 4)SWELLING IN RELATION TO TENDON MOVES ALONG WITH TENDON&BECOMES FIXED WHEN MUSCLE CONTRACTS 5)IN CONNECTION WITH VESSELS &NERVES DO NOT MOVE ALONG VESSELS OR NERVES BUT MOVE TO A LITTLE EXTENT AT RIGHT ANGLES TO THEIR AXES 6)IN CONNECTION WITH BONE IS ABSOLUTELY FIXED IRRESPECTIVE OF MUSCLE CONTRACTION
  101. 101. PERCUSSION LIMITED VALUE IN SWELLINGS  1.TYMPANIC NOTE  ENTEROCELE  PHARYNGOCELE  2.HYDATID THRILL  HYDATID CYST
  102. 102. AUSCULTATION BRUIT OVER PULSATILE &VASCULAR SWELLINGS BRUIT  SHORT,MEDIUM PITCHED MURMUR HEARD OVER THE SWELLING WITH EACH PULSE WAVE  EX:ANEURYSM  THYROTOXIC GOITRE
  103. 103. REGIONAL LYMPH NODES DRAINING LYMPH NODES EXAMINED IF INVOLVED NEXT HIGHER GROUP EXAMINED IF THE SWELLING ITSELF IS ALYMPH NODE EXAMINE  1.OTHER LYMPH NODAL GROUPS  2.SPLEEN  3.LIVER  TO EXCLUDE SYSTEMIC CAUSE  EXAMINE DRAINAGE AREA TO EXCLUDE INFECTION
  104. 104. PRESSURE EFFECTS 1.OVER BONE – FEEL FOR BONY EROSION  AS IN DERMOID CYST 2.IN LIMBS  DISTAL PULSES- PRESSURE OVER ARTERIES  EDEMA &DILATED VEINS – PRESSURE OVER VEINS  PARESIS& MUSCLE WASTING – PRESSURE OVER NERVES MOVEMENTS OF JOINTS
  105. 105. WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE *Image via Bing
  106. 106. SPINAL LIPOMA*Image via Bing
  107. 107. GENERAL EXAMINATION
  108. 108. Question time? WHAT IS UNIVARSAL TUMOUR? WHAT ARE THE PROCESSESS FUSING IN EXTERNAL ANGULAR DERMOID? WHAT IS THE TUMOUR SHOWING POSITIVE SLIP SIGN? WHAT IS THE SITE AT WHICH A LIPOMA MOST COMMONLY UNDERGOES SARCOMATOUS CHANGE? WHAT IS THE MOST COMMON SITE FOR CYSTIC HYGROMA? WHAT IS THE OTHER NAME FOR BASAL CELL CARCINOMA?
  109. 109. THANKS FOR PATIENT LISTENING*Image by 40501877@N04 via Flickr

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