Swelling – History

Swelling analysis

  • Site (where is it?)
  • Onset (sudden or gradual?)
  • Course (does it increase or decrease in size with the time?)
  • Duration (when did it appears?)
  • Other swellings (do you have other swellings?)
  • Relation to other symptoms like pain (is it painful?)
  • Possible Cause (why do you think you’ve got it?)

Scrotal examination

 

Scrotum

Plan for examination of the scrotum
Scrotal neck Junction between corrugated & smooth skin

At root of penis

At the pubic tubercle

Skin
Tunica Normally not felt except there is fluid If Minimal fluid it is felt by benching

If large amount of fluid it is felt as swelling

Testis Testicular sensation

Size

Epididymis
Cord Thickness

Vas felt like tough structure

Inguinal region Inguinal lymph nodes (that drain scrotal skin)
Penis Shaft for Hypospadias

Epispadias

Circumcision
DRE Prostate

Seminal vesicles

Perineum
Abdomen Para-aortic lymph nodes

Maldescended testis

Neck Left  supraclavicular LNs ( Verchow’s sign)

 

Aim of examination in case of scrotal swelling is to answer 4 questions

Can you get above the swelling?

Can you identify the testis and the epididymis?

Is the swelling is translucent?

Is the swelling is tender?

and these are examples for how you can comment on your examination of scrotum.

Hydrocele

  1. “Enlarged right side of the scrotum”
  2. Look to back of the scrotum and penis
  3. “No signs of inflammation (scars, sinuses or dilated veins)”
  4. “No cough impulse and not reducible (بيرجع؟)”
  5. “I can get above the swelling so it is pure scrotal swelling”
  6. Feel the swelling (relation to testis and epidydimis)
  7. Transillumination

Varicocele

  1. Examine in supine position after standing
  2. Inspection normal
  3. Feel bag of worms
  4. May feel cough impulse or thrill
  5. Separate from testis
  6. Can get above it
  7. No transillumination

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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

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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

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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

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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

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