Breast Examination

Breast examination

Exposure: All of the top half of the trunk, Compare both breasts and Start with the normal side (MUST ASK FOR A CHAPERONE)

Inspection

Position (Patient sitting 90˚ then raise arms above her head then hands on her hip)

Breast Size, Symmetry, Contour, 6 areas (4 quadrants, Tail and Inframammary surface)
Skin Dimpling, Puckering, Peau d’orange, Cancer encrust, Discoloration, Nodule and Ulceration or SCAR
Nipple and areolae Destruction, Depression (retraction or inversion), Discoloration, Displacement, Deviation, Discharge and Duplication
Axillae and arms
Supraclavicular fossae

Palpation

Position (Patient sitting 45˚)
By Flat of fingers, Bimanual examination and Ask the patient to find the lump if you did not find it
Breast ‘6 areas’ (4 quadrants, Tail and Inframammary surface)

Lump

Number
Site
Shape
Size
Surface
Skin and color
Special signs

Relations to the surroundings

Mobility

Relation to skin
  • Freely mobile
  • Tethered
  • Fixed
Relation to muscles Hands by sides

Hands press in sides

Relation to chest wall
Other swellings
Temperature
Tenderness
Edge
Reducibility
Solid, fluid or gas Consistence

Fluctuation

Discharge
Milk each quadrant towards the nipple to know which duct is the source of the discharge
Axillae “axillary L.N.s” (anterior, medial, posterior, lateral and apical)
Supraclavicular fossae

General examination

Abdomen Hepatomegaly, Ascites and Nodule in Douglas pouch
Chest
Lumbar spine
  • Percussion
  • Movements
  • Straight leg raising and Ankle jerks

Continue reading “Breast Examination”

Facial nerve Examination

 

Facial nerve palsy

Inspection

  1. General: Loss of facial expressions
  2. Eyelids: on blinking, the affected side closes after the normal eyelid (Bell’s sign – the eyeballs moves vertically upwards when the eye is closed)
  3. Eyes: widened palpebral fissures
  4. Nasolabial folds: flattened on the affected side
  5. Mouth: the affected side droops and moves less when talking

Palpation

  1. Occipitofrontalis: “ارفع حواجبك
  2. Orbicularis oculi: “زر على عينيك
  3. Orbicularis oris: “ورينى سنانك
  4. Buccinators: “انفخ

Complete examination

  1. Test taste (chorda tempani)
  2. Test hearing (hyperacusis N. to stapedius)
  3. Cause (history – scar)

Parotid Gland Examination

 

Parotid Gland

Inspection

Number
Site Parotid region
Shape Parotid shape if diffuse parotid enlargement
Size
Surface
Skin and color Scar, fistula
Special signs Relation to chewing food

Palpation

Relations to the surroundings:

Mobility

Relation to skin Freely mobile, Tethered or Fixed
Relation to muscles Masseter “جز على سنانك” and Sternomastoid
Relation to nerves Facial nerve examination
Relation to artery Superficial temporal artery pulse
Ear Elevation of ear lobule
Other swellings
Temperature
Tenderness
Edge
Reducibility ?
Solid, fluid or gas
  • Consistence
  • Fluctuation

Open the mouth to assess

  • Ability to open
  • What happen to the lump?
  • Parotid lump usually diminish in size due to tension of parotid facsia
  • Dryness of the mouth
  • Swellings of submandibular glands and its duct (bimanual examination)
  • Parotid duct
  • Deep part of the parotid gland

Continue reading “Parotid Gland Examination”

Thyroid Examination

 

Thyroid Examination

General examination for thyroid status
Hands
  1. Increased sweating
  2. Palmer erythema
  3. Pulse and water hummer pulse (Tachycardia, AF, Any arrhythmia except HB and Sleeping pulse >90 bpm)
  4. Fine tremors (by a sheet of paper on out stretched hands with palms facing downwards)
  5. Thyroid acropachy
  6. Onycholysis
  7. Areas of vitilligo
Eyes

(stabilize the head)

  1. Lid retraction (front – Dalrymple’s sign)
  2. Lack of forehead wrinkling on looking upwards without moving the head (front – Joffroy’s sign)
  3. Lid lag (front – Von Graefe’s sign)
  4. Defective convergence (front – Moebius’s sign)
  5. Ophthalmoplegia (front)
  6. Exophthalmos (back)
  7. Loss of hair of outer third of eyebrows
Other systemic manifestations
  1. Pretibial myxoedema
  2. Proximal myopathy
  3. Signs of heart failure
  4. Gynecomastia

Thyroid Examination

Local examination

Inspection

Palpation

Position Patient: Neck extended

Doctor: In front of the patient

Patient: Slightly flexed

Doctor: Front then behind

Exposure All head till clavicle All head till clavicle
Comment on

Description

  • lump (as any swelling)
  • Scar of previous operation (Healing or Complication)

Relation to surrounding

Sternomastoid Muscle contraction
  • Tilt the patient’s head to the same side
  • Pinch the muscle
  • Ask him to swallow
Skin Ask patient to swallow Ask patient to swallow
Carotid artery
  • Normal site
  • Equal volume
  • Displacement
  • Weak pulse
  • ‘Berry’s sign’
Trachea Move up and down

While standing the patient put fingers on gland and ask him to swallow will feel the gland and the larynx go up

Put fingers to stop descent of the gland while the larynx goes down

Manubrium Is lower edge seen? Is lower edge felt?
Neck L.N.s
Neuro-Vascular Bundle
Percussion Resonant or dull?
Auscultation Upper pole of the gland

To hear systolic bruit if gland is highly vascular as in toxic goiter

Continue reading “Thyroid Examination”

Neck examination

 

Neck examination

Lymph nodes examination (up-and-down technique)
  1. Palpate from the chin backwards to below the ears (submental – submandibular – parotid glands – pre-auricular)
  2. Move your hand behind the ears (post-auricular) and palpate DOWN the anterior border of sternomastoid to the clavicle (anterior triangle including jugulodigastric)
  3. Move laterally along the clavicle (supraclavicular – infraclavicular) then UP the posterior border of sternomastoid (posterior triangle)
  4. Finish by palpating back of the scalp (occipital nodes)
+ Face and scalp examination (thyroid examination if the swelling in front of the neck)

+ Area above the umbilicus (breast examination in females)

+ ENT examination searching for primary site of infection or neoplasia

+ Abdominal examination (hapatomegaly and splenomegaly) and the rest of lymphoreticular system (other groups of lymph nodes)

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image source: http://pedsinreview.aappublications.org/content/34/5/216

Continue reading “Neck examination”

Examination of Oral Cavity

This is a simplified plan to examine the mouth and the tongue..

The Mouth and the tongue

Tongue

Anterior 2/3
  • Size
  • Shape
  • Papillae
  • No fissures
  • Congenital tie
  • Short ferenulum
  • Ankyloglossia
  • Congenital fissures
  • Geographical tongue
Taste

Corda tempani (facial nerve)

Sensation

Lingual nerve (trigeminal nerve)

Motor

Hypoglossal nerve

Paralyzed tongue deviate to the paralyzed side

Posterior 1/3 Not accessible except mirror or under anaesthesia
Lump (as any swelling)
Ulcer (as any ulcer)

Do not forget examination of cervical lymph nodes

TAKING HISTORY FROM A PATIENT WITH An oral cavity problem

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms Relation to the main complaint

  • Swelling
  • Ulcer
  • Pain
  • Causes of chronic superficial glossitis that predispose malignancy (six Ss)
    • Syphilis, Smoking, Sharp tooth, Spirits, Spices and Sepsis
  • Sequelae of malignancy of the tongue

Spread

Local (posterior 2/3)

Asphyxia

Lymphatic

Lymph nodes enlargement

Infiltration

Lingual artery

Haemorrhage

Lingual nerve

Pain referred to ear

Recurrent laryngeal nerve

Hoarseness of voice

Infection

Halitosis

Pain

Necrosis

Aspiration pneumonia

Ankyloglosia

Dysarthria

Dysphagia

cachexia

Causes of ulceration of the tongue

(Traumatic, Neoplastic, inflammatory, ischemic, autoimmune,..)

  • Aphthous ulcer
  • Trauma (dental)
  • Non-specific glossitis
  • Chancre
  • Gumma
  • TB
  • Carcinoma
  • Lichen planus
  • Herpetic ulcers
Causes of macroglossia
  • Multiple haemangiomata
  • Multiple lymphangiomata
  • Plexiform neurofibromatosis
  • Amyloid infiltration
  • Infiltrating carcinoma
  • Muscle hypertrophy (cretins)
Causes of swelling of the jaw
  • Infection
    • Alveolar (dental) abscess
    • Acute osteomyelitis
    • Actinomycosis
  • Cysts (odontomes)
    • Dental cyst
    • Dentigerous cyst
    • Other odontogenic cysts and cystic tumors
  • Neoplasm
    • Benign
      • Fibrous dysplasia
      • Giant cell granuloma
      • Odontogenic tumors
    • Locally invasive
      • Adamantinoma
    • Malignant
      • Osteogenic sarcoma
      • Malignant lymphoma (Burkitt’s tumor)
      • Secondary tumors (by direct invasion or blood spread)
  • Epulides
    • Fibrous epulis
    • Granulomatous epulis
    • Myeloid epulis
    • Sarcomatous epulis
    • Carcinomatous epulis
Dental Cyst vs. Dentigerous Cyst

Dental cyst

Dentigerous cyst

Adult Young age
In relation to carious tooth In relation to missing tooth
Maxilla Mandible
Incisors and canines Premolars and molars
Unilocular Tooth inside

Scalp Examination

 

Scalp examination

Inspection

Palpation

Lump

  • Number
  • Site
  • Shape
  • Size
  • Surface

Skin and color   Alopecia

  • Special signs

Pulsations Metastasis

Cirsoid aneurysm

Impulse on cough Meningiocele

Transillumination

  • Relations to the surroundings .. Mobility
  • Relation to skin
  • Relation to muscles
  • Relation to bone
  • Other swellings
  • Temperature
  • Tenderness
  • Edge
  • Reducibility
  • Solid, fluid or gas
  • Consistence
  • Fluctuation
Ulcer (as any ulcer)
Differential diagnosis of scalp disorders
  • Traumatic
    • Heamatomas
    • Cephalhaematoma
  • Sebaceous cyst
  • Neoplastic
    • Benign
      • Ivory osteoma
      • Lipoma
      • Haemangioma (capillary, cavernous and arterial)
      • Neurofibroma
    • Malignant
      • Primary
        • Basal cell carcinoma
        • Squamous cell carcinoma
        • Malignant melanoma
        • Leukaemia
        • Myeloma
      • Secondary
        • Breast
        • Bronchus
        • Thyroid
        • Prostate
        • Kidney
  • Infective
    • Cock’s peculiar tumor
    • Tinea capitis
    • Abscess
  • Others
    • Psoriasis
    • Seborrhoeic dermatitis
    • Meningiocele
    • Dermoid cyst

Anatomical Significance

 SCALP Layer Content Surgical importance
S Skin Hair follicles
  • Alopecia
  • Sebaceous Cyst
  • If multiple Turban
C CT Blood vessels
  • Bleeds a lot
  • Good healing
  • Site of heamatomas
nerves Layer of local anesthesia
Fibrous tissue septa Heamatoma will be localized
A Aponeurosis
L Loose areolar tissue Loose
  • Dangerous
  • Spread of infection
  • Mobile Cutaneous swelling
  • Layer of descalping
Emissary veins
P Periosteum