Lumps and BumpsCommon sense rules for examining lumps • Perform whole examination unless specified...
Transcript of Lumps and BumpsCommon sense rules for examining lumps • Perform whole examination unless specified...
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Lumps and Bumps
Ms Rose Ingleton
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Outline
OSCE:
• How to examine lumps
in general
• Stomas
• Hernias
Extra info on:
• Breast Lumps
• Neck Lumps
• Scrotal Lumps
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Common sense rules for examining lumps
• Perform whole examination
unless specified
• Don’t ignore it (and
don’t be afraid to touch it!)
• Remember special ‘tests’
E.g. thyroid, hernias etc
• Consider investigations (but if unsure, USS)
• If you don’t know what it is,
JUST DESCRIBE IT
If in doubt:
• INSPECT• PALPATE• (?)AUSCULTATE
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Examining lumps
• Location
• Size/Shape
• Texture
• Colour
• Surface
• Overlying skin changes
• Surrounding structures
• Temperature
• Movement?
• Pain?
• Reducible?
• Transillumination?
• Pulsatile/Peristaltic?
• Auscultation?
• Associated S/S
• Red flag signs
• Always be concerned if hard, nodular, irregular
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Investigations
If in doubt, ultrasound scan always reasonable
• Neck – USS
• Breast – triple assessment (mammo/USS)
• Testicular - USS
• Hernia – USS/CT
• ?Biopsy/FNA
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Stomas
• Examine as part of abdominal examination
• State the obvious from the end of the bed
• Ask to examine it properly including contents of
the bag
• Use hints to decide what stoma it is and know
common pathologies
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What stoma is it?
• Location
• Shape
• Contents of bag
• How many openings
• (Patient Demographic)
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Location
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Shape
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Contents
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Openings
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End Ileostomy = usually inflammatory bowel diseaseAlso multiple bowel Ca, familial polyposis, ischaemic bowel, toxic colitis
Loop ileostomy = usually to protect anastomosisCancer, inflammatory bowel disease
End colostomy = usually cancer, DD (esp. emergencies)
Loop colostomy = usually palliation or protect
anastomosis
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Patient Demographics
Is it likely I have
been treated for
colorectal cancer?
(Less than 2 per 100,000 males under 20
dx with bowel cancer per year)
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Additional examination points
• Looks healthy vs. unhealthy (pink, moist, shiny)
• Pink vs. dusky (ischaemia) or black (necrotic!)
• Producing waste successfully
• Prolapse?
• Retraction?
• Infection?
• Skin excoriation? (ileostomy)
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Don’t forget, stomas can get their
own lumps too!
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Hernias
• Examine as part of abdominal
examination
• State the obvious from the end of
the bed
• Use extra manoeuvres specific to
hernias for complete examination
• Use hints to decide what hernia it is
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Hernias
• Inguinal
• Femoral
• Umbilical
• Incisional
• Epigastric
• (Spigelian)
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Hernias
• Not all lumps in the abdomen are ‘hernias’
– lipoma, cyst, abscess, lymph node, varix
• Describe it
• Use location to identify subtype
• Reducible vs. irreducible (incarcerated)
• Remember it may disappear on lying flat
• Know the risks/complications
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Examining hernias
• Perform abdominal examination as you would normally
• During palpation examine ‘lump’ as you would any other. Can you feel peristalsis? Is it reducible? Does it cause pain?
• Auscultate – are there bowel sounds?
• At the end of the examination ask the patient to stand –does the lump get bigger?
• Ask patient to cough – palpate. If swelling enlarges = positive cough impulse. Diagnostic for hernias.
• Determine what hernia it is (if you can!)
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Which groin hernia is it?
Inguinal hernias
most common in
men AND women
Femoral hernias
almost never seen
in men
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Which groin hernia is it?
Above/medial to pubic
tubercle = inguinal
Below/lateral to pubic
tubercle = femoral
Looks like it’s above/part of the
groin crease (or within scrotum)
= inguinal
Looks like it’s below the groin
crease= femoral
Inguinal – through inguinal
canal, parallel to ligament
Femoral – through femoral
canal, under ligament
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Which groin hernia is it?
Indirect vs. direct inguinal hernia
• Reduce lump
• Press hand over deep inguinal
ring (halfway between pubic
tubercle and ASIS)
• Ask patient to cough
• If hernia protrudes =
must be direct (as you are
obstructing deep ring)
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Hernias
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Hernias
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Hernias
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• Most hernias do not suffer complications
• Is the patient clinically well? Is it painful?
• Incarcerated vs. obstructed vs. strangulated
• Strangulated hernia = medical emergency
• High risk of recurrence
Additional examination points
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Neck/Breast/Scrotal lumps
• Location
• Size/Shape
• Texture
• Colour
• Surface
• Overlying skin changes
• Surrounding structures
• Temperature
• Movement?
• Pain?
• Reducible?
• Transillumination?
• Pulsatile/Peristaltic?
• Auscultation?
• Associated symptoms
• Red flag signs
• Always be concerned if hard, nodular, heterogenous
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Breast Lumps
• Fibroadenoma – smooth, painless, v. mobile, single,
• Cyst – fluid-filled, well-defined
• Abscess – red, hot, painful, discharge/pus
• Duct ectasia – behind nipple +/- inversion, green
discharge
• Fat necrosis – firm, +/- pain, recent trauma
• Cancer – heterogenous, nipple inversion, discharge,
skin change
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Neck Lumps
• Lymph nodes - usually posterior triangle
Reactive – painful, mobile, short/appropriate history
Malignant – mets/lymphoma. Look for associated symptoms
• Thyroid – midline, move with swallowing
Benign – diffuse/nodular goitre
Tumour – single, hard, heterogenous
• Salivary glands – parotid/submandibular/sublingual
Tumour, sialolithiasis (stones), mumps (B/L)
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Neck Lumps
Cysts – soft, smooth, cystic (liquid/semi-liquid)
• Thyroglossal cyst - midline, moves on tongue protrusion
• Branchial cyst developmental abnormalities, lateral
• Cystic hygroma neck, may not appear until adolescence.
CH more posterior, transilluminates.
• Sebaceous cyst – soft, mobile, common on face and neck
• Lipoma
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Scrotal Lumps
• Indirect hernia – separate from testicle, can’t get above it
• Varicocele – dilated veins, feels like ‘bag of worms’
• Hydrocele – smooth, painless, fluid-filled, transilluminates
• Spermatocele – non-growing posterior nodule
• Tumour – painless, solid hard lump, irregular
• Epididymitis – posterior painful swelling
• Sebaceous cyst
• Undescended testes
• Torsion – acute onset swelling + pain
= surgical emergency
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Any questions?