Post on 22-May-2015
POWER POINT
CLINICS
DR.M.RAVI CHANDRA,M.S(G.S)ASST. PROF. OF SURGERYRIMS SRIKAKULAM
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
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EXTERNAL ANGULAR DERMOID
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EXTERNAL ANGULAR DERMOID
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SUB MANDIBULAR DERMOID
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DERMOID CYST OF SCALP
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DERMOID CYST IN MID LINE
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ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW
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MENINGOCELE
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HUMAN TAIL?
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
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MULTIPLE LIPAMATOSIS
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HYDREDENITIS SUPPURATIVA OF AXILLA
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EXTEXNSIVE SCARRING UNDER THE ARMS DUE TO HYDREDENITIS SUPPURATIVA
3.SHAPE
SPHERICAL
OVOID
KIDNEY /BEAN SHAPED/RENIFORM
IRREGULAR
4.SIZE
5.SURFACE
COLOUR
SPECIAL CHARACTER OF SURFACE
OVERLYING SKIN
A)COLOUR
ARTERIAL HAEMANGIOMA – BRIGHT RED
VENOUS HAEMANGIOMA— PURPLE
MALIGNANT MELANOMA- BLACK
BENIGN NAEVUS – BLACK
RANULA –BLUE
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CAPILLARY HAEMANGIOMA OVER FORE HEAD
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BENIGN NEVUS
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HERIDITARY DYSPLASTIC NAEVUS SYNDROME
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MALIGNANT MELANOMA
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MALIGNANT MELANOMA OF FOOT
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RANULA OF RIGHT SUBLINGUAL
b)Character of surface
TWO CHARACTERISTIC SURFACES ON INSPECTION CAULIFLOWER SURFACE – SQUAMOUS
CELL CARCINOMA FILIFORM BRANCHED SURFACE –
PAPILLOMA (IRREGULAR NUMEROUS BRANCHED SURFACE)
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SQUAMOUS CELL CARCINOMA
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FILIFORM SURFACE OF PAPILLOMA
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INDONESIAN TREE MAN
H.P.V. AFFECTING HANDS &LEGS
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
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ABSCESS
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ABDOMINAL WALL ABSCESS
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NASAL ABSCESS
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INFECTED SEBACEOUS CYST WITH PUNCTUM
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SOFT TISSUE SARCOMA
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
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
POSITIVE COUGH IMPULSE
HERNIA
MENINGOCELE
VARICOCELE
SAPHENA VARIX IN CHILDREN CRYING ACTS AS
COUGHING
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
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
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
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
11)MOVEMENT WITH TONGUE PROTRUSION
IN CASE OF MID LINE NECK SWELLINGS
EG:THYROGLOSSAL CYST &FISTULA
WHY?
ATTACHED TO FORAMEN CAECUM OF TONGUE
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)
PALPATION DEFINITE CLUE TO DIAGNOSIS
METHODICAL,FOLLOW DEFINITE ORDER
BE GENTLE
SHOULD NOT HURT THE PT.
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
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
3.SIZE& SHAPE
CONFIRM VERTICAL & HORIZONTAL DIMENSIONS
NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION
4.SURFACE
WITH PALMAR SURFACE SMOOTH –CYSTIC SWELLINGS LOBULARWITH SMOOTH BUMPS-LIPOMA NODULAR –MULTI NODULAR
GOITRE/MATTED LYMPH NODES IRREGULAR - CARCINOMA
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SMOOTH SURFACE OF A SEBACEOUS CYST
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M..N.G. WITH NODULAR SURFACE
5.EDGE
1)WELL DEFINED & REGULAR – BENIGN NEOPLASMS
2)WELL DEFINED & IRREGULAR –MALIGNANT NEOPLASM
3)ILLDEFINED &DIFFUSE –INFLAMMATORY SWELLINGS
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ABSCESS WITH ILL DEFINED MARGINS
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LIPOMA WOTH WELL DEFINED MARGINS
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LARGE LIPOMA WITH WELL DEFINED MARGINS
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IRREGULAR BORDERS IN CARCINOMA BREAST
SLIP SIGN
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
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6.CONSISTENCY
SOFT – LIPOMA CYSTIC- CYSTS &CHRONIC
ABSCESSES FIRM –FIBROMA HARD BUT YIELDING-CHONDROMA BONY HARD-OSTEOMA STONY HARD- CARCINOMA VARIABLE CONSISTENCY-
MALIGNANCY
HOW TO ASSESS CONSISTENCY SOFT – EAR LOBULE,ALAE OF NOSE
FIRM- TIP OF NOSE,UN CONTRACTED MUSCLE
HARD -BRIDGE OF NOSE,CONTRACTED MUSCLE
SIGN OF MOULDING OR INDENTATION 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
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
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
7.FLUCTUATION
TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER
IMPLIES PRSENCE OF FLUID IN THE SWELLING
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
LAW BEHIND FLUCTUATION!
PASCAL’S LAW PRESSURE EXERTED TOA FLUID IS
TRANSMITTED EQUALLY IN ALL THE DIRECTIONS
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PRINCIPLES WHILE DOING FLUCTUATION TEST
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
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
CROSS FLUCTUATION
FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER
SEEN IN COMPOUND PALMAR GANGLION PSOAS ABSCESS PLUNGING RANULA
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
BRILLIANTLY TRANSILLUMINANT SWELLINGS
1.CYSTIC HYGROMA
2.EPIDIDYMAL CYST
3.MENINGOCELE WITH THIN SKIN
4.RANULA
5.CONGENITAL HYDROCELE
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
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
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
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
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
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
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
IN AN ABDOMINAL LUMP?
KNEE ELBOW POSITION WHEN KEPT IN KNEE ELBOW POSITION
PULSATIONS DISAPPEAR – TRANSMITTED PULSATIONS
PULSATIONS PERSIST –EXPANSILE PULSATIONS
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
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
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
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
PERCUSSION
LIMITED VALUE IN SWELLINGS 1.TYMPANIC NOTE
ENTEROCELE PHARYNGOCELE
2.HYDATID THRILL HYDATID CYST
AUSCULTATION
BRUIT OVER PULSATILE &VASCULAR SWELLINGS
BRUIT SHORT,MEDIUM PITCHED MURMUR
HEARD OVER THE SWELLING WITH EACH PULSE WAVE EX:ANEURYSM THYROTOXIC GOITRE
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
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
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WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE
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SPINAL LIPOMA
GENERAL EXAMINATION
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?
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THANKS FOR PATIENT LISTENING