As with the history, so with the examination, there are two aspects of the examination: that concentrating on the specific complaint, the lump or the pain, and that reviewing the whole patient. Examination of the whole patient, particularly before an operation, should be as thorough as that performed in a routine medical examination. In examining a specific surgical feature, it is important to follow an accurate clinical description.
Diagnosis of a lump
First, determine in what anatomical plane the lump is situated: the skin, subcutaneous tissue, muscle, tendon, nerve or bone, or is it attached to some particular organ? Second, determine the physical characteristics of the lump: is it tender or nontender? If not acutely tender, determine: its size —measure in centimetres; shape — round or flattened, regular or irregular; and consistency — very soft (like a jelly), soft (as relaxed muscle), firm (like a contracted muscle), hard (as a contracted biceps) or stony hard.
Having completed the examination, it is a useful discipline to consider whether the lump is congenital, traumatic, inflammatory (acute or chronic), neoplastic (benign or malignant) and, if malignant, a primary or secondary neoplasm. If it is none of these, a degenerative, metabolic or hormonal disorder may provide the key.
Important specific signs
• Thrill: three fingers are placed on a swelling, the middle one being pressed firmly and the lateral ones lightly. The middle finger is percussed firmly, and after each stroke, the percussing finger is allowed to rest momentarily. The thrill felt by the adjacent fingers confirms the presence of fluid under pressure.
• Sign of compression: when the swelling is compressed it diminishes in size considerably or disappears. When the pressure is released it refills slowly. Characteristically the sign is related to vascular swellings.
• Sign of indentation: certain cysts containing putty-like material can be moulded — thus the swelling is indented by the finger. Faeces can be indented.
• Sign of an aneurysm: difficulty can be encountered in deciding whether the pulsation of a swelling is transmitted or whether the swelling itself is pulsating. If the swelling is expansile and pushes the fingers apart, then it is an aneurysmal swelling, while if the swelling is deflected by the pulsation it is transmitted.
An ulcer is a loss of epithelial lining; when examining an ulcer.
Attention should be paid to the following points.
• Shape: is it round, oval, irregular or serpiginous?
• Edge: this may slope downwards towards the crater, be undermined, punched out or everted.
• Floor: the most typical is a slough in the base of an ulcer.
• Base: whether indurated or attached to deeper structures.
• Surrounding tissues: examine for signs of inflammation, pigmentation or the presence of varicosities.
After an ulcer has been examined it is essential to consider the lymphatic drainage, and in particular the regional nodes.
Ulcers are of five main varieties:
• the septic ulcer with sloping edges;
• the tuberculous ulcer with undermined edges;
• the carcinomatous ulcer with everted hard edges;
• the rodent ulcer with barely visible pearly edges;
• the syphilitic punctated ulcer.
In describing an examination, terms should be used specifically and correctly.
A fistula implies a tunnel connecting two epithelial surfaces. A sinus is a blind track opening on to the skin or a mucous surface.
Fluid may discharge from a sinus or fistula; the discharge should be examined and noted: is it blood, blood-stained, clear, bile like, serous, faecal or purulent? The type of fluid may give a clue to the possible diagnosis.
Lymphangitis is inflammation within a lymphatic vessel and appears as a red line often leading to an inflamed regional lymph node.
Phlebitis is a thrombosed and inflamed vein — it is more usual in superficial veins often associated with varicose veins, which are tender and hard.
Cellulitis is inflammation of tissues, usually superficial or subcutaneous tissue. The part affected is swollen, tense and tender. Later it becomes red, shiny and boggy. It may progress to an abscess, which is the presence of pus in the tissue concerned.
Inflammation, which is the earlier stage of cellulitis, is the presence of redness, swelling, heat and tenderness, often associated with the loss of function.
Crepitus is a term used in a variety of conditions but in each having a fundamental diagnostic importance. Bone crepitus is noted as coarse grating on movement of a bone —it is very painful to the patient, and an unmistakable diagnosis of a fracture of a bone. Joint crepitus is elucidated by placing one hand on a joint and passively moving the joint with the other hand: fine, evenly spaced crepitations are present in many subacute and chronic joint conditions. Coarse, irregular crepitations signify osteoarthritis.
The crepitus of tenosynovitis is found over an inflamed tendon sheath when effusion has occurred into the sheath.
The crepitus of subcutaneous emphysema is due to gas in the tissues: a peculiar crackling sensation is imparted to the examining fingers. It may be due to trauma when gas is released into the tissues after a rib fracture or damage to the oesophagus, or due to gas-forming organisms as in gas gangrene.
Translucency: there are occasions when swellings containing clear fluid lie adjacent to the skin. When a torch is shone through the swelling it lightens the area, confirming the diagnosis.
Ballotement is when a swelling can be tapped away from the examining finger, often due to fluid adjacent to the swelling. The term also describes the ability to palpate bimanually a renal swelling and to tap the kidney forward from the loin to the examining fingers of the other hand on the abdomen. A swelling may be balloted from the pelvis, by a finger in the vagina, to the examining abdominal hand.
Fluctuationis a specific term to elucidate the presence of fluid. Two watching fingers are placed on either side of a swelling and a central displacing finger presses momentarily. An impulse is felt by the watching finger confirming the presence of fluid, provided the sign is elicited in more than one plane
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