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Examination of the swelling final .pptx
- 1. Examination of the swelling Dr Deepa M.S., Assistant professor Department of General Surgery
- 2. • You should wash your hand in the presence of the patient before beginning the physical examination • A new patient warrants a complete examination, regardless of chief complaint • The sequence of comprehensive examination should maximize the patient’ s comfort • As a beginner, you should avoid interpreting your findings for the patient
- 3. Important points before Examination ● Introduce yourself ● Explain yourself ● Get permission from the patient ● Ideal exposure ● Treat with respect
- 5. • General survey: general state of health; height, weight, build, sexual development, motor activity, facial expression 1state of awareness or level of consciousness. • Vital signs: blood pressure, pulse number and respiratory rate. • Skin: color, lesions. Inspection and palpation of hair Comprehensive Physical examination
- 7. INSPECTION • z. SITE- EXACT ANATOMICAL LOCATION IMPORTANT AS SOME SWELLINGS OCCUR IN ATYPICAL POSITION WHICH IS DIAGNOSTIC • EXAMPLES —POST AURICULAR DERMOID-BEHIND EAR —EXTERNAL ANGULAR DERMOID —LATERAL END OF EYE BROW —MENINGOCELE- OVER THE BACK IN MIDLINE
- 14. DERMOID CY STIN MID LINE
- 15. ATYPOCAL LOCATION OFDERMOID - MEDIAL END OF EYE BROW
- 18. 2.NUMBER • USUALLY SINGLE , SOMETIMES MULTIPLE • MULTIPLEEXAMPLES —MULTIPLE NEUROFIBROMATOSIS(VONRECK LING HAUSENS DISEASE) —MULTIPLE LIPAMATOSIS(DERCUMS DISEASE) —DIAPHYSEAL ACLASIS —HYDRADENITIS SUPPURATIVA —MULTIPLE LYMPHOGLANDULAR SWELLINGS
- 23. inflammation Infected sebum Sebaceous gland Hair follicle
- 25. • SPHERICAL • OVOID • KIDNEY /BEAN SHAPED/RENIFORM • IRREGULAR 3.SHAPE
- 26. 4.SIZE • EXACT SIZE USING A MEASURING TAPE ° LONGITUDINAL & TRANSVERSE ON INSPECTION • DEPTH BETTER JUDJED ON PALPATION • USUAL LY N OT ED IN CE N TI M ETR FS
- 27. • COLOUR • SPECIALCHARACTER OFSURFACE • OVERLYING SKIN 5.SURFACE
- 28. A)COLOUR • ARTERIAL HAEMANGIOMA — BRIGHT RED • VENOUSHAEMANGIOMA— PURPLE • MALIGNANT MELANOMA- BLACK • BENIGN NAEVUS — BLACK • RANULA —BLUE
- 36. b)Character of surface • TWO CHARACTERISTIC SURFACES ON INSPECTION CAULIFLOWER SURFACE —SQUAMOUS CELL CARCINOMA —FILIFORM BRANCHED SURFACE —PAPILLOMA {IRREGULAR NUMEROUS BRANCHED SURFACE)
- 41. Skin over lying swelling • TENSE , SHINY WITH PROMINENT VEINS — SARCOMA • RED & EDEMATOUS — INFLAMMATORY • BLACK PUNLTUM — SE BACEOUS SYST • PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS • SCAR PREVIOUS OPERATION(REGULAR SCAR WITH SUTURE MARKSj — INJURY(REGULAR SCAR) — SUPPURATION(PUCKERED ,BROAD &IRREGULAR) — PEAU - D ORANGE APPEARANCE(MA1NLY IN CA. BREAST) • ULCERS
- 47. 6.VISIBLE PULSATIONS • PULSATION —A MOVEMENT OR INCREASE INSIZE SYNCHRONOUS WITH EACH HEART BEAT —z TYPES • EXPANSILE PULSATIONS —SWELLINGS ARISING FROM ARTERIES EX: ADRTIC ANEURYSM , CAROTID BODY TUMOUR • TRANSIMITTED PULSATIONS — SWELLINGS CLOSE TO ARTERIES • REM EMBER NOT TO TOUCH THE PATIENT DURING INSPECTION
- 49. 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
- 50. POSITIVE COUGH IM PULSE • HERNIA • MENINGOCELE • VARICOCELE • SAPHENA VARIX —I N CHILDREN CRYING ACTS AS COUGHING
- 51. 8.VISIBLE PERISTALSIS • OBSERVED IN ABDOMINAL LUMPS AND INGUINAL SWELLINGS • CONGENITAL HYPERTROPHIC PYLORIC STENOSIS — VISIBLE GASTRIC PERISTALYSIS • INGUINAL HERNIAS(ENTEROCELE) INTESTINAL PERISTALYSIS • LUMPS DUETOINTESTINAL MALIGNANCY PERISTALYSIS IS SEEN
- 53. 9.MOVEMENT WITH RESPIRATION • 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
- 54. 10.Movement with deglutition • IN CASE OF NECK SWELLINGS —SWELLINGS MOVING WITH DEGLUTITION • THYROT D SWELLING • THYROGLOSSAL CYST • THYROGLOSSAL FISTULA • SUBHYOID BURSA • PRE/PARA TRACHEAL LYMPH NODES • EXTRINSIC CARCINOMA OF LARYNX
- 56. WHY THYROID MOVES UP WITH DEGLUTITION? • THYROID IS ENCLOSED IN PRETRACHEAL FASCIA • PTFATTACHES TO THYROID&CRICOID CARTILAGES(BERRY'SLIGAVENT) • SUPERIOR CONSTRICTOR MUSCLE CONTRACTION DURING DEGLUTITION • THESE CARTILAGES MOVE UP • ALONG WITH THESETHYROID MOVES
- 57. 11)MOVEMENT WITH TONGUE PROTRUSION • IN CASE OF MID LINE NECK SWELLINGS • EG:THYROGLOSSALCYST&FISTULA • WHY? —ATTACHED TO FORAMEN CAECUM OF TONGUE
- 58. 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)
- 59. PALPATION • DEFYNITE CLUETO DIAGNOSIS • METHODICAL,FOLLOW DEFINITE ORDER • BEGENTLE • SHOULD NOT HURTTHE PT.
- 60. • 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
- 61. 2.TENDERNESS • PAIN DUETO PRESSURE EXERTED OVER THE SWELLING ISTENDERNESS • PALPATEGENTLY OVER ALLTHE AREA • IT ISASIGN • FEATURE OF —INFLAMMATORY SWELLINGS —SWELLING RELATED TO NERVES - NEUROFIBROMA
- 62. 3.SIZE& SHAPE • CONFIRM VERTICAL & HORIZONTAL DIMENSIONS • NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION
- 63. 4.SURFACE • WITH PALMAR SURFACE —SMOOTH— CYSTICSWELLINGS —LOBULARWITH SMOOTH BUMPS LIPOMA —NODULAR —MULTI NODULAR GOITRE/MATTED LYMPH NODES —IRREGULAR - CARCINOMA
- 67. • 1)WELL DEFINED & REGULAR — BENIGN NEOPLASMS • 2)WELL DEFINED & IRREGULAR — MALIGNANT NEOPLASM • • 3)ILLDEFINED & DIFFUSE - INFLAMMATORY SWELLING
- 71. IRREGULAR BORDERS IN CARCINOMA BREAST
- 72. SLIP SIGN • TO DEFFERENTIATE BETWEEN LIPOMA AND CYSTIC SWELLING(BOTH HAVE WELL DEFINED ,REGULAR BORDERS) • WHEN EDGE OFA SWELLING IS PALPATED WITH A FINGER ,IF IT SLIPS UNDER THE FINGER,. DOES NOTYIELD TO IT , IT IS A LIPOMA, IF IT YIELDS TO FINGER IS A CYST
- 73. 6.CONSISTENCY • SOFT — LIPOMA • CYSTIC- CYSTS &CHRONIC ABSCESSES • FIRM — FIBROMA • HARD BUTYIELDING-CHONDROMA • BONY HARD-OSTEOMA • STONY HARD- CARCINOMA • VARIABLE CONSISTENCY- MALIGNANCY
- 74. HOW TO ASSESS CONSISTENCY • SOFT —EAR LOBULE,ALAE OF NOSE • FIRM- TIP OF NOSE,UN CONTRACTED MUSCLE • HARD -BRIDGE OF NOSE,CONTRACTED MUSCLE
- 75. SIGNOFMOULDING ORINDENTATION • LOOKF ORTHISSIGNIN 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) • S E E N IN • 1.SEBACYOUS CYST • 2.DERMOID CY ST • 3.COLONIC MASS WITH FAECAL MATTER
- 76. PAGET' S TEST • DONE FOR SMALL SWELLINGS TO KNOW THE CONSISTENCY(CYSTIC/SOLID) • THE CENTRE AND PERIPHERIES ARE PALPATED WITH INDEX FNGER —CYSTIC SWELLING FEELS SOFTER AT CENTRE THAN PARIPHERY —SOLID SWELLING FEELS FIRMER ATCENTRE THAN PERIPHERY
- 77. SPECIAL TESTS • DONE IN CASE OF SOFT/CYSTIC SWELLING —7 FLUCTUATION —8.TRANSILLUMINATION - g.COUGH IMPULSE —zo.REDUCIB(LITY —zz.COMPRESSIBILITY • IN SOLID SWELLINGS DIRECTLY PROCEED TO TEST FOR RELATION TO OTHER STRUCTURES
- 78. 7.FLUCTUATION • TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER • IMPLIES PRSENCE OFFLUID INTHE SWELLING
- 79. 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
- 81. LAW BEHIND FLUCTUATION! • PASCAL’ S LAW — PRE 5SURE EXERTED TO A FLUID IS TRAN OMITTED EQUALLY IN ALL THE DIRECTIONS
- 82. PRINCIPLES WHILE DOING FLUCTUATION TEST • ALWAYS PERFORM IN zDIRECTIONS AT RIGHT ANGLES TO EACH OTHER • TWO FINGERS SHOULD BE KEPTAS FAR APART AS POSSIBLE • FREELY MOBILE SWELLINGS SHOULD BE FIXED FIRST(AS IN HYDROCELE) • SMALL SWELLINGS —WATCHING FINGER & DISPLACING FINGER • VERY LARGE SWELLINGS MORETHAN ONE FINGFR SHOLD BE USED
- 83. 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
- 84. CROSS FLUCTUATION • FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER • SEENIN —COMPOUND PALMAR GANGLION —PSOASABSCESS —PLUNGING RANULA
- 85. 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
- 86. BRILLIANTLY TRANSILLUMINANT SWELLINGS • 1.CYSTIC HYGROMA • 2.EPIDIDYMAL CYST • 3.MENINGOCELE WITH THIN SKIN • 4.RANULA • 5.CONGENITAL HYDROCELE
- 87. 9.COUGH IMPULSE • PERFORMED IN SWELLINGS LIKELYTO BE IN CONTACT WITH ABDOMINAL ,CRANIAL ,SPINAL ORCHESTCAVITY • SWELLING IS HELDWITH FINGERS AND PATIENTISASKEDTO COUGH • IFTHESWELLING BECOMES TENSEOR INCREASES IN SIZE IT IS POSITIVE COUGH IMPULSE • IN CHILDREN CRYING ACTS AS OUGH
- 88. • INCONTINUITY WITH ABD.CAVITY —HERNIA —ILIO-PSOAS ABSCSS - LUMBAR ABSCESS • INCONTINUITY WITH PLEURAL CAVITY —EMPYEMA NECESSITANS • INCONTINUITY WITH SPINAL /CRANIAL CAVITY —SPINAL/CRANIAL MENINGOCELE
- 89. 10.REDUCIBILITY • INDICATION SAMEAS FOR COUGH IMPULSE • PATIENT IS ASKED TO RELAX • SWELLING IS COMPRESSED FROM ALL THE SIDES UNIFORMLY • REDUCIBLE SWELLINGS DECREASESIN SIZE OR COMLETELY DISAPPEAR
- 90. REDUCIBLE SWELLINGS • z.HERNIA • z.MENINGOCELE •3 VARICOCELE • q.SAPHENAVARIX —A REDUCIBLE SWELLING ONCE REDUCED REAPPEARS ONLY BY STRAINING,COUGHING, OR FORCE OF GRAVITY AS IT INVOLVES DISPLACEMENT OF VISCERS TO AN ADJOINING CAVITY
- 91. 11.COMPRESSIBILITY • WHEN PRESSURE IS APPLIED TO A SWELLING IT DECREASES IN SIZE AND WHEN PRESSURE IS RELEASED SWELLING REGAINS ITS SIZE ITSELF WITH OUTANY EXTERNAL FACTORLIKE STRAINING OR COUGHING • CHARECTARISTIC SIGN OF VASCULAR HAEMANGIOMA
- 92. 12.PULSATILITY • WHEN FINGER IS PLACED OVER A PULSATILE SWELLING IT RAISESWITH EACH BEAT • TO TYPES OF PULSATIONS ° TRANSMITTED PUL5ATION5— SEEN IN SWELLINGS PRESENT NEAR AN ARTERY EX:CA STOMACH LUMP NEAR ABO.AORTA • EXPANSILE PULSATIONS-SEEN IN SWELLINGS ARISING FROM ARTERIES • EX:AORTIC ANEURYSM
- 94. 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. IN AN ABDOMINAL LUMP? • KNEE ELBOW POSITION —WHEN KEPT IN KNEE ELBOW POSITION • PULSATIONS DISAPPEAR — TRANSMITTED PULSATIONS • PULSATIONS PERSIST —EXPANSILE PULSATIONS
- 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. 14.RELATION TO SURROUNDING STRUCTURES • z)SUBCUTANEOUS TISSUE —SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT ADHERENT TO SKIN OR UNDERLYING MUSCLE —LIPOMA-PUSHED SIDEWAYS PUCKERING 15 SEEN IN SOME PLACES — DUE PRESENCE OF FIBROUS SEPTA • z)DEEP FASCIA —SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS MOBILE AS SUBCUTANEOUS SWELLING S - ITl5 DIFFlCULT|MAKE OUT FlXATlONTO DEEP FA5ClAAS DEEPFASCACANNOTBEMADETAUT • EVEN IF TUMOUR IS ATTAC HED TO UNDERLYING DEEP
- 99. 3)RELATION TO MUSCLE • RELATION SHIP TO MUSCLE IS KNOWN BY THROWING THE CONCERNED MUSCLE INTO CONTRACTION —TUMOURS IN SUB CUTANEOUSTISSUE- 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. 4)SWELLING IN RELATION TO TENDON • MOVES ALONG WITH TENDON&BECOME5 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. PERCUSSION • LIMITED VALUE IN SWELLINGS —z.TYMPANIC NOTE • ENTEROCELE • PHARYNGOCELE —z.HYDATID THRILL • HYDATID CYST 3.Dull—solid swellings
- 102. AUSCULTATION • BRUITOVERPULSATILE&VASCULAR SWELLINGS • BRUIT —SHORT,MEDIUM PITCHED MURMUR HEARD OVER THE SWELLING WITH EACH PULSE WAVE • EX:ANEURYSM • THYROTOXIC GOITRE
- 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 = EXAM NE DRAIN MEAR A TO EXCLUDE INFECTION I E
- 104. PRESSURE EFFECTS • z.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. WASTTNGOFTHENAR MUSCLES DUE PRESSUREOVER MEDIAN NERVE