history taking and physical examination skills

1. BY: DR. MOHAMMED A.
(SURGEON), ST PETER HOSPITAL ADDIS
ABABA , ETHIOPIA

2. OBJECTIVES
 At the end of this lecture students will be able to :
 Recall surgical anatomy of breast and thyroid gland
 Acquire history taking skill about breast and thyroid gland
complaints
 Perform physical examination of the breast and thyroid gland
 Able to report physical finding of an examination

3. CLINICAL EXAMINATION OF BREAST

4. SURGICAL ANATOMY OF BREAST
 Female breast
 Extend 2nd to 6/7th ribs
 Mid axillary line to lateral border of sternum
 Enters axilla as axillary tail
 Contains 15-20 lobules
 Lymphatic drainage is to axilla(75%) , internal
mammary, ifra and supraclavicular nodes
 Nipple areolar complex
 Nipple: conical projection from center of areola
contains smooth muscle and elastic fibers
 Thin pigmented skin, the areola contain sebaceous
gland

5. EMBRYOLOGY AND CONGENITAL
VARIATION
 Mammary milk line: Ventral bands of thickened ectoderm
 Polymastia :Accessory breasts
 Polythelia accessory nipples
 Amastia: absence of breast
 Symmastia : is a rare anomaly recognized as webbing between the
breasts across the midline
 Gynecomastia refers to an enlarged breast in the male.
 Can be physiologic in the neonatal period, adolescence, and
senescence.
Mammary
milk line
polythelia
Unilateral
amastia Symastia
Axillary
polymastia

6. HISTORY TAKING
 Follow the formal history
taking steps
 Common presenting
complaints are:
 Breast lump or mass
 Breast discomfort or pain
 Nipple discharge
 This complaints could be
normal variations or
pathological findings

7. HISTORY TAKING CONT.……
Breast
lump

8. HISTORY TAKING CONT.……
 Pain of the breast
 Duration of the complaint
 Bilateral or unilateral
 Association with menstruation , Fever, nipple
discharge, breast lump
 Previous history
 Aggravating and releifing factor.
 Trauma history
Painless lump Painful lump
Cyst Cyst
Fibroadenoma Breast abscess
Fibroadenosis Fibroadenosis
Fatnecrosis Periductal mastitis
Antibioma Caricinoma (rare)
Carcinoma

9. HISTORY TAKING CONT.……
 Discharge from nipple
 Duration of illness
 Associated pain, fever, lump
 Color, consistency and odor of the discharge?
Type of nipple discharge Possible cause
Serous Early pregnancy,
fibroadenosis
Milk Neonate, late pregnancy,
lactation, puberty
Yellow ,brown ,green Fibroadenosis
Thick and creamy Duct ectasis
Purulent Retr-areolar abscess, TB,
breast abscess
Bloody Intraductal ca, intraductal
papilloma, Paget's disease

10. TECHNIQUES OF BREAST EXAMINATION
 General rules
 Be systematic during examination
 Divide breast in to four quadrants for reporting the
finding
 Follow general rule of physical examination
 Self introduction
 INSPECTION, PALPATION,
percussion and auscultation
 Always compare the breast and start from the healthy one.
 Characterize and describe your findnig

11. TECHNIQUES OF BREAST EXAMINATION CONT. …..
 INSPECTION:
 Do it with adequate exposure and in 4 different
positions
1. Sitting with arms at sides
2. Inspect with arms over head
3. Inspect with hands pressed against hips.
4. Inspect leaning forward

12. TECHNIQUES OF BREAST EXAMINATION CONT. …..
Breasts Look for
• Symmetry
• Shape or contour of breast
• Skin color
• Skin tethering
• Ulcer
• Prominent veins or edema with dimpling like skin of orange (peau d’orange)
Nipple • Everted, flat or inverted(recent change or long standing)
• Cracking or eczema
• Bleeding or discharge
Areola Observe for
• Abnormal reddning
• Thickening

13. TECHNIQUES OF BREAST EXAMINATION CONT. …..
On
INSPECTION
look for
Inverted
nipple
Skin color
change
Symmetry of
breast
Color and
texture of
skin
Ulcer of
breast
Contour
of breast

14. TECHNIQUES OF BREAST EXAMINATION CONT. …..
 PALPATION
 Best performed when the breast tissue is
flattened.
 The patient should be supine
 Use the pads of the 2nd, 3rd, and 4th fingers,
keeping the fingers slightly flexed
 Be systematic: cover all quadrant in systematic
way
 The vertical strip pattern is currently the best
validated technique for detecting breast
masses
 Concentric pattern
 Radial paths

15. TECHNIQUES OF BREAST EXAMINATION CONT. …..
 Points to be noted in case of breast lump during palpation
 Location : by quadrant or clock, with centimeters from the nipple
 Temperature
 Tenderness
 Size: in centimeter
 Shape: round or cystic, disclike, or irregular in contour
 Number
 Mobility
 in relation to the skin, pectoral fascia, and chest wall
 Consistency: soft, firm or hard
 Margin/delineation: well circumscribed or not
Don’t forget to palpate and squeeze
the nipple especially if there is
discharge

16. THE AXILLAE
 Sitting position is preferred for axillary
examination
 Inspection:
 See if there is rash , infection, abnormal
pigmentation
 Palpation
 Use your right hand to examine the left
axilla and vice versa
 To examine left axilla support patients left
forearm with your left hand and patient relaxed,
put your right hand fingers in axilla all groups
LNs in each wall of the axillae.
 Same steps with opposite hand applied to
examine the other axillae

17. CLINICAL EXAMINATION OF THYROID GLAND

18. SURGICAL ANATOMY OF THYROID
 Extend from the level of C5 – T1
vertebra
 Each lobe: 5 x 3 x 2 cm
(height/width/depth)
 Total weight is about 15 to 30 gm

19. SURGICAL ANATOMY OF THYROID CONT. ….
 Pre-tracheal fascia:
 Provides fascial sheaths for the thyroid gland,
larynx, pharynx, trachea, oesophagus and the
infrahyoid strap muscles.
 Extends from hyoid bone to fibrous pericardium
 Parathyroids and venous plexus lie between layers

20. LYMPHATIC DRAINAGE OF THYROID GLAND

21. EMBRYOLOGY
 The thyroid gland arises as a midline diverticulum at the floor of
pharynx
 It is endodermal in origin which also forms the hyoid bone and
larynx
during descend
 During descend the analge stayed connected to the foramen
cecum
via an epithelial-lined tube known as the thyroglossal duct
 Some congenital abnormality
 Thyroglossal Duct Cyst and Sinus
 Lingual Thyroid
 Ectopic Thyroid.

22. HISTORY TAKING
 Follow the standard history taking
format
 Patient may present with complaint
of:
 Anterior neck swelling
 Symptom of hypothyroidism
 Symptom of hypothyroidism
 Symptom of malignancy
 Pressure symptoms on neck(tightness
feeling on throat, difficult of breathing,
difficult of swallowing)
Symptoms of hyper
/hypothyroidism of hyper or
hypothyroidism
 Hyperthyroidism
 Irritable/nervous/restlessness
 Good appetite but weight loss
 Diarrhea
 Heat intolerance
 Palpitation
 Oligomenorrhea/miscarriage
 Hypothyroidism
 Apathetic/blunting of thought/fatigue
 Poor appetite but Weight gain
 Constipation
 Cold intolerance

23. HISTORY TAKING CONT. …..
 Swelling
 Ask for duration, associated pain, fever, recent
change
 History of associated hyper or hypothyroidism
symptoms
 Related pressure symptoms
 Voice change
 Pain
 Characterize pain
 Goiter painless
 Inflammatory painful
 Malignancy start painless later painful
Cause of midline neck swelling
Thyroid
• Physiologic goiter
• Multinodular goiter
• Grave’s disease
• Hashimotos thyroiditis
• Thyroglossal cyst
• Thyroid cyst
• Solitary adenoma
• Thyroid carcinoma
• Sub-acute thyroiditis(de
quervein’s, riddle’s )
Non thyroid
• Lipoma
• Dermoid cyst
• Epidermal cyst
• Abscess
• Lyphoma

24. TECHNIQUES OF PHYSICAL EXAMINATION OF THYROID
 General rule
 Apply the standard format INSPECTION, PALPATION, Auscultation, Percussion.
 Sitting position is preferable
 To inspect be Infront of the patient but for palpation be at the back
 For inspection ask the patient to slightly tilt the head back ward but for palpation flex or
neutral position of the neck

25. TECHNIQUES OF PHYSICAL EXAMINATION
 Inspection
 Tip the patient’s head slightly back.
 Skin color, rash, ulcer, edema, scar, redness
 Look for your land marks thyroid cartilage, cricoid cartilage
 swelling (location, shape)
 Inspect the region below the cricoid cartilage to identify the
contours of the gland
 Observe the movement of the swelling during swallowing and
tongue protrusion
 After completing the anterior inspection look from lateral side
and see the swelling and other eye signs

26. PHYSICAL EXAMINATION CONT. ……
 Inspection cont. …….
 On inspection we should be able
to report
 shape (spherical, horizontal)
 Location(midline, lateral, bilateral)
 Skin feature
 Pulsatility : present/absent
 Movement with deglutition: absent/
present
 Movement with protrusion of tongue:
absent /present
 Occasions where thyroid swelling
may not move with swallowing:
 Anaplastic thyroid carcinoma
 Locally advanced carcinoma of the thyroid
 Retrosternal extension with impaction or infiltration
 Riddle's thyroiditis with encasement of trachea
 Huge thyroid where movement is difficult to
appreciate

27. PHYSICAL EXAMINATION CONT. ……
 Palpation can give us information about :
 Volume
 Consistency
 Surface
 Mobility in relation to surrounding structure
 Shape Of the thyroid gland

28. PHYSICAL EXAMINATION CONT. ……
 Palpation: (posterior approach is best)
 Palpate by being behind the patient and fix
one with one hand while palpating by the
other
 Place your hand around the neck of the
patient, flex the neck to relax deep fascia, ask
the patient to swallow to see the border.
 Locate your anatomical land marks
 Determine extent of the swelling
 Reporting should include: temperature,
tenderness, plane of swelling, shape, surface,
location

29. PHYSICAL EXAMINATION CONT. ……
 Lahey’s method
 Examiner stands Infront of the patient
 Gland pushed to one side
 Ideal to palpate margins
 Crile’s method
 Thumb on the gland patient asked to swallow
 Help to assess nodularity

30. PHYSICAL EXAMINATION CONT. ……
 Percussion: do it over the sternum to see
retrosternal extension  Auscultation: over the lower or upper
pole of the gland to hear bruits

31. SIGNS OF HYPER OR HYPOTHYROIDISM
 Hyper thyroidism
 Hand sign
 Fine tremor
 Palmar erythema
 Clubbing
 Cardiovascular
 Tachycardia, atrial fibrillation
 Eye sign
 Lid lag
 Lid retraction
 Exophthalmos
 Ophthalmoplegia: patient cant look up ward
 Ecchymosis
 Other
 Thyroid bruit
 Wasting/ proximal myopathy
 Pretibial myxedema
 Hypothyroidism
 Bradycardia
 Slow deep voice
 Dry skin
 Edematous face
 Slow reflex
 Loss of outer third of eyebrow

32. PHYSICAL EXAMINATION CONT. ……
Von graefe’s sign(lid lag) Jofforoy’s sign: absence of forehead
wrinkling while patient asked to upward
with face inclined down ward
Stellwag sign: staring eye
, infrequent blinking
Darymple sign
(lid retraction)
Pemberton’s sign(
raising hand cause facial
engorment intrathoracic
goiter)