Clinical - General Swelling examination

MRCS Clinical Examination

Scheme & Test Interpretetion

Modified  by MAW 2009

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ليغطى 99% من الفحص العملى و تفسيره

ملحق به ورق اخر لأهم الأسئلة

نفع الله الناس به ووفق الجميع لطلب العلم

 

Swellings (Lumps & Bumps)

History                                                                                   

                                                                                       

1-         Onset (When 1st noticed), Duration (Long/ Short)                                                         

2-         Complaint (Pain / Other lump / Change)                                    

3-         Treatment (Previous surgery / Insulin in diabetic ulcer)               

4-         Cause (Trauma)                                                                       

For any swelling examine:

SKIN & SCT

MUSCLE

 L.N.

VESSELS

Swelling Examination

Introduce yourself

Exposure:  till area L.N. drainage

UL → elbow (epitrochlear L.N.) although nonspecific + axillary L.N.

LL → groin (inguinal L.N.) although non-specific + popliteal L.N. for  leg

H & N → to (clavicle cervical L.N.)

Trunk & Back → axilla (axillary L.N.)

1-    Inspection (4SMS) Be Fluent & very fast in swelling examination even forget points

a-  Site

b-  Shape

c-  Size (in cms)

d-  Skin: Scars  فى اى جروح او عمليات(Ask about hidden scars?) – Sinuses – dilated vs – Redness

e-   Relation to Muscle: contraction ms → more palpable = superficial to ms

           → less palpable = deep to ms

- Other sweelings (same or L.N.)

f-   Special ccc: impulse on cough – thrill – pulsatile

2-    Palpation Ask about painful area first (TT ESCR SMSL)

a-  Temperature

b-  Tenderness  

c-  Edge (well defined/ Ill defined/ Slippery)

d-  Surface (Smooth/ Irregular)

e-  Consistency (soft/ firm/ hard/ cystic) - if soft vs cystic do Paget test  

f-  Relations:      Mobility in 2 perpendicular directions

Relation to Skin (not attached/ teethered/ fixed) &

Relation to Muscle: contraction ms → more palpable = superficial to ms

                     → less palpable = deep to ms

g-  Special Tests

·  Fluctuation (Paget’s test1) & Trans-illumination if suspect cystic (querry soft vs cystic)

·  Compressibility2 / Reducibility3                 ·  Pulsatile4 / Expansile5

·  Thrill                                                       ·  Fixation (with skin & deep structures)

h-  L.N. & other swellings (very..very imp.)

3-         Percussion (Dull / Resonant)

4-         Auscultation (Bruit / Bowel sounds)

I would like to finish my examination by:

 1-        Examination of draining lymph nodes هام جدا

 2-          Assessing the neurovascular status of the limb/area (feel distal pulse)

1 Paget test: Applying intermittent pressure by the index finger of one hand between two fingers of the other hand

2 Compressiblity: Lump disappears when compressed, then reform spontaneously when compressing hand is removed

3 Reducibility: Lump can be 'pushed' away into a different place, lump will not reform spontaneously and requires an

    additional force e.g. gravity, raised intra-abdominal pressure

4 Pulsatile : If  a finger is placed on either side of a lump → pushed one direction (lump is near to an artery)

5 Expansile: If  a finger is placed on either side of a lump → forced apart with every pulsation