Surgical History for ULCER & Lump

8/18/2019 Surgical History for ULCER & Lump

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Notes on

History Taking


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“Always give the patient

your whole attention.. Treat patients as the

rational, intelligent,human beings they are.”


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“..and never take short

cuts”


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!uestions"pen

#losed

$eading !.


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“%ou shall not use

leading &uestions, all&uestions should leave

the patient with a 'reechoice o' answers”


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“(on)t write and talk to

the patient at the sametime”


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Never start with a

diagnosis in mind..Always start with a

*%+T"+.


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“-t)s better not to know

the diagnosis made bythe patient or other

doctors because nonemay be correct.”


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“/ it)s essential to know

them 0% H1A2T”


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“ %our understanding and ability to solvethe practical problems o' clinicalexamination can only be clari3ed by're&uent bedside practice.

4 examine as many patients as youcan.

4 Nothing can be learnt without

're&uent practice.4 2epetition is the secret o'learning”


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“The A2T o' history

taking 5 clinicalexamination.”


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6 #on3dentiality


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Examination of a

LUMP


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7hat is a lump8A compact mass o' a substance8

*welling8


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0asic approach to a

lump89. History

:. 1xamination

-nspection alpation

ercussion

auscultation


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History o' a lump7hen was the lump 3rst noticed8(oesn)t mean it appeared then

7hat drew your attention to it8;elt it, saw it

ain

*omeone else noticed it

7hat are the symptoms8


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History o' a lumpHow has it changed since it 3rst appeared8*i?e, shape, =uctuates8

tenderness8

(oes it ever disappear8

Any others be'ore8

7hat do you think the cause is8


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1xamination o' a lump-nspection

alpation

ercussionAuscultation


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1xamination o' a lump*ite


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1xamination o' a lump*kin

*ur'ace#olor@ red in=amed, purple, black necrotic,

*mooth

0lack punctum *ebaceous cyst

eau d) orange#auli=ower sur'ace


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1xamination o' a lumpulsation

(epending on the site@#ough impulse@ Abd, thorax, pelvic

ressure eBects

+ovement with swallowing


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1xamination o' a lump@

palpation Temp"ver lump, and compare with surroundings

7arm well vascularised , also in/.8

Tenderness in=ammation, nerve

*ur'ace

*mooth

cystic$obular with bumps lipoma

Nodular goiter

-rregular #a


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1xamination o' a lump@

palpation1dge, wit tips7ell de3ned, regular benign

7ell de3ned, irregular malignant

-ll de3ned in=ammatory

*lipping edge lipoma

con3rm si?e


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#onsistency*o't lipoma

;-2+

HA2(, stony hard, bony, calci3ed

1xamination o' a lump


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#onsistencyCariable malignant

1xamination o' a lump


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*o't1ar lobule

Ala o' nose

;irmDncontracted muscle

Tip o' nose

Hard#ontracted muscle

2idge o' nose


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1xamination o' a lump#%*T-# lump$ock 'or moulding@ indentation *ebaceous ,

dermoid,

;luctuation

Thrill


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1xamination o' a lump-' the lump is cystic, then do@;luctuation-' large mass in : planes, car'ul Tissue

=uctuation

i' small 3x it between : 3ngers, press with thethird

-' it =uctuates

then do Trans4illumination clear =uid

;luid thrill


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1xamination o' a lump#ough impulse@becomes tense

-ncrease in si?e

2educibility@compress the lump uni'ormly

1.g. hernia

displacement

#ompressibilityvascular hemangioma

compresses,, then expanses back rapidly

ulsetile


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1xamination o' a lump+oves with respiration


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To which tissue is the lump 3xed8*kin#an)t pinch the skin above it

Tethering8 -ndirectly attached

0one Totally immobile

+oves with the bone

Tendon@ moves with it on active, 3xed oncontraction against resistance, mobile on rightangle not parallel


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To which tissue is the lump 3xed8 Tell the patient to contract the muscle

sub!+ore rominent,

remain mobile

+uscle;ixed, immobile

+obile at right angle to 3bers on relaxing themuscle

0elow muscleless prominent, diEcult to palpate


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alpation


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alpation Temp

Tenderness

*ur'ace*mooth cystic

$obular with bumps lipoma

Nodular goiter

-rregular #a

1dge, wit tips7ell de3ned, regular benign

7ell de3ned, irregular malignant

-ll de3ned in=ammatory

*lipping edge lipoma

con3rm si?e

#onsistancy*o't lipoma

#%*T-# $ock 'or moulding@ indentation *ebaceous , dermoid, ;luctuation Thrill

;-2+

HA2(, stony hard, bony, calci3ed

-' the lump is cystic, then do@

;luctuation-' large mass in : planes, car'ul Tissue =uctuation

i' small 3x it between : 3ngers, press with the third

-' it =uctuates then do

Trans4illumination clear =uid

;luid thrill


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percussion*mall no need8

Tympanic gas

Hydatid thrill


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AuscultationHighly vasculari?ed Aneurysm


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2egional 1xamination$ymph nodesNeighboring structures

Foints


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*ystemic


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To study the disease

without books is tosail an unchartedsea,

7hile to study bookswithout patients is

not to go to sea atall

*ir 7illiam "sler9GI49I9I


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Examination of an

ULE!


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7hat is it “Dlcer”8(iscontinuity o' any epithelial membrane

#an be on@*kin

+ucosal J-

“-t is a de'ect with loss o' epidermis and atleast part o' the dermis”


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0asic approach to an

ulcer89. History:. Dlcer examination

. ;ocal examination

. *ystemic examination


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History o' an ulcer7hen was the ulcer 3rst noticed(oesn)t mean it appeared then

7hat drew your attention to it8ain

0leeding

(ischarge

*mell

7hat are the symptoms8-nter'eres with daily activity8


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History o' an ulcerHow has it changed since it 3rst appeared8*i?e, shape, discharge8

Healed and broken8

Any others be'ore8

7hat do you think the cause is8


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1xamination o' an ulcer-nspectionalpation


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1xamination o' an ulcer-nspection@*ite

*i?e*hape

*ur'ace

1dge 5 (epth

+argin

*urroundings


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1xamination o' an ulcer9. *ite@

in anatomical terms, in relation to nearby structures, landmarks

Cenous +edial malleolusArterial dorsum o' 'oot

Trophic, neuropathic weight bearing areas

2odent 'ace, nose

Tuberculous neck, axilla, groin

+alignant lips, tongue, breast


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(+


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1xamination o' an ulcer:. *i?e@+easure, don)t guess

(


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1xamination o' an ulcer. *hape@

%ou can draw it


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1xamination o' an ulcer. *ur'ace@Healing ulcer

ink healthy granulation tissue,+inimal serous discharge

*ome bleeding on touch

No slough


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1xamination o' an ulcer. *ur'ace@-schemic Dlcer

oor granulation Tuberculous0luish unhealthy

*kin death, 'ull thickness*olid, brown or grey


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1xamination o' an ulcer. *ur'ace@*cab


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1xamination o' an ulcerK. 1dge 5 (epth@

1dge@ the union between the =oor and the margin

*loping

unched4out

Dndermined

2olled

1verted


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Healing ulcer

Cenous ulcer can have it


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Trophic ulcer

Neuropathy L (+

Arterial ischemia


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ressure necrosissub! 'at is more susceptible to pressure than

the skin


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0##

“2odent ulcer”

*low growth

*ite8


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1xamination o' an ulcerM. +argin@transitional ?one, the area between the ulcer and the normaltissue

Healing2ed 0lue 7hite

-n=amed

2ed, irregular;ibrosed Thick 7hite, 3rm, no blue growing epithelium

#hronic, not healing


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+argin@ the Function btwn normal epithelium5 the ulcer


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1xamination o' an ulcer. *urroundings @in'ected shiny, red, edematous

varicose

heperpigmintation, Tuberculous multiple


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1xamination o' an ulceralpation*urroundings

Temp Tenderness

2elation to deeper [email protected].+alignant ulcers will obviously be 3xed to

deeper structure by in3ltration


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1xamination o' an ulceralpationDlcer

1dge so't@ healing

;irm@ non4healing

Hard@ malignant

;loor, granulation0ase -' small, between : 3ngers

-' large, 'rom the =oor


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1xamination o' an ulcer$ymph Nodes+alignancy

Hard, discrete, non tender-n'ected*o't, tender


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1xamination o' an ulcer2egion and *ystemicAccording to the type

#olor, hair, pulses, temp,


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lini"al feat#res of Martorell #l"er

+artorell ulcers most commonly occur on the outer aspect o' back o' the lowerleg o'ten Fust above the ankle. "ver the Achilles tendon is another common site.

A signi3cant proportion o' patients report the ulcer began a'ter skin trauma, butmore commonly it starts as a pain'ul red blister or patch which turns blue then

ulcerates.Dlcer characteristics may include@

1xtreme pain out o' proportion to the si?e and appearance o' the ulcer L it istypically described as Ostrong to excruciating)

*olitary or symmetrical, aBecting the same site on both lower legs

2ed4purple in=amed ulcer edge

1pisodes o' sudden enlargement due to another area o' skin death-rregular shape

*atellite ulcers

(eep, exposing underlying tendons

;ailure to respond to usual treatments 'or leg ulcers.


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lini"al feat#res of Martorell #l"er

+artorell ulcers most commonly occur on the outer aspect o' back o' the lowerleg o'ten Fust above the ankle. "ver the Achilles tendon is another common site.

A signi3cant proportion o' patients report the ulcer began a'ter skin trauma, butmore commonly it starts as a pain'ul red blister or patch which turns blue then

ulcerates.Dlcer characteristics may include@

1xtreme pain out o' proportion to the si?e and appearance o' the ulcer L it istypically described as Ostrong to excruciating)

*olitary or symmetrical, aBecting the same site on both lower legs

2ed4purple in=amed ulcer edge

1pisodes o' sudden enlargement due to another area o' skin death-rregular shape

*atellite ulcers

(eep, exposing underlying tendons

;ailure to respond to usual treatments 'or leg ulcers.


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+arFolin DlcerA'ter longstanding, non4healing ulcer They trans'orm into malignant ulcer

The previous image


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THAN$ %U

Surgical History for ULCER & Lump

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