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POWER
 POINT
CLINICS
DR.M.RAVI CHANDRA,M.S(G.S)
ASST. PROF. OF SURGERY
RIMS SRIKAKULAM
INSPECTION
 1. SITE- EXACT ANATOMICAL LOCATION
  IMPORTANT AS SOME SWELLINGS OCCUR
  IN A TYPICAL POSITION WHICH IS
  DIA...
EXTERNAL ANGULAR DERMOID




*Image via Bing
EXTERNAL ANGULAR DERMOID
*Image via Bing
*Image via Bing
SUB MANDIBULAR DERMOID




*Image by 12498905@N02 via Flickr
*Image by 48276084@N00 via Flickr
DERMOID CYST OF SCALP




*Image via Bing
DERMOID CYST IN MID LINE




*Image via Bing
ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW




*Image via Bing
*Image via Bing
MENINGOCELE
*Image via Bing
HUMAN TAIL?




*Image via Bing
2.NUMBER

 USUALLY SINGLE , SOME TIMES MULTIPLE
 MULTIPLE EXAMPLES
  MULTIPLE NEUROFIBROMATOSIS(VON RECK
     LING HAUS...
*Image via Bing
*Image via Bing
MULTIPLE LIPAMATOSIS




*Image via Bing
HYDREDENITIS SUPPURATIVA OF AXILLA




   *Image via Bing
*Image via Bing
*Image via Bing
EXTEXNSIVE SCARRING UNDER THE ARMS DUE TO
        HYDREDENITIS SUPPURATIVA




*Image via Bing
3.SHAPE

 SPHERICAL


 OVOID


 KIDNEY /BEAN SHAPED/RENIFORM


 IRREGULAR
4.SIZE
5.SURFACE

 COLOUR


 SPECIAL CHARACTER OF SURFACE


 OVERLYING SKIN
A)COLOUR

 ARTERIAL HAEMANGIOMA – BRIGHT RED

 VENOUS HAEMANGIOMA— PURPLE

 MALIGNANT MELANOMA- BLACK

 BENIGN NAEVUS ...
CAPILLARY HAEMANGIOMA OVER FORE HEAD




   *Image via Bing
BENIGN NEVUS
BENIGN NEVUS
    *Image via Bing
HERIDITARY DYSPLASTIC NAEVUS SYNDROME




  *Image via Bing
*Image via Bing
MALIGNANT MELANOMA




*Image via Bing
*Image via Bing
MALIGNANT MELANOMA OF FOOT




*Image via Bing
RANULA




*Image via Bing
*Image via Bing
RANULA OF RIGHT SUBLINGUAL




*Image via Bing
b)Character of surface

 TWO CHARACTERISTIC SURFACES ON
 INSPECTION
   CAULIFLOWER SURFACE – SQUAMOUS CELL
    CARCINOMA...
SQUAMOUS CELL CARCINOMA




*Image via Bing
*Image via Bing
SCC OF TONGUE




*Image via Bing
FILIFORM SURFACE OF PAPILLOMA




*Image via Bing
INDONESIAN TREE MAN




*Image via Bing


                  H.P.V. AFFECTING HANDS &LEGS
c)Skin over lying swelling
   TENSE , SHINY WITH PROMINENT VEINS – SARCOMA
   RED &EDEMATOUS – INFLAMMATORY
   BLACK PU...
ABSCESS




*Image via Bing
ABDOMINAL WALL ABSCESS
*Image via Bing
NASAL ABSCESS




*Image via Bing
INFECTED SEBACEOUS CYST WITH PUNCTUM




*Image via Bing
SOFT TISSUE SARCOMA




*Image via Bing
*Image by 88761406@N00 via Flickr
*Image via Bing
6.VISIBLE PULSATIONS

 PULSATION
  A MOVEMENT OR INCREASE IN SIZE
   SYNCHRONOUS WITH EACH HEART BEAT
  2 TYPES
    EX...
7.VISIBLE COUGH IMPULSE

 PERFORMED WHEN SWELLING IS OVER
  ABDOMEN,CHEST,SPINAL CANAL OR
  CRANIUM
 COUGH IMPULSE
  VI...
POSITIVE COUGH IMPULSE

 HERNIA


 MENINGOCELE


 VARICOCELE


 SAPHENA VARIX
  IN CHILDREN CRYING ACTS AS COUGHING
8.VISIBLE PERISTALYSIS

 OBSERVED IN ABDOMINAL LUMPS AND
  INGUINAL SWELLINGS
 CONGENITAL HYPERTROPHIC PYLORIC
  STENOSI...
9.MOVEMENT WITH
RESPIRATION
 SEEN IN ABDOMINAL LUMPS
 SWELLINGS ARISING FROM
    STOMACH
    LIVER
    SPLEEN
    GA...
10.Movement with deglutition

 IN CASE OF NECK SWELLINGS
  SWELLINGS MOVING WITH DEGLUTITION
    THYROID SWELLING
    ...
WHY THYROID MOVES UP WITH DEGLUTITION?


 THYROID IS ENCLOSED IN PRETRACHEAL
    FASCIA
   PTF ATTACHES TO THYROID &CRIC...
11)MOVEMENT WITH TONGUE PROTRUSION


 IN CASE OF MID LINE NECK SWELLINGS


 EG:THYROGLOSSAL CYST &FISTULA


 WHY?

   ...
12)PRESSURE EFFECTS

 WHEN SWELLING IS PRESENT ON LIMBS
  AN AXILLARY SWELLING WITH LIMB EDEMA –
   LYMPHNODAL SWELLING
...
PALPATION
 DEFINITE CLUE TO DIAGNOSIS


 METHODICAL,FOLLOW DEFINITE ORDER


 BE GENTLE


 SHOULD NOT HURT THE PT.
1.TEMPERATURE
 IT IS AN ABSOLUTE STANDARD PRACTICE
  TO TEST FOR TEMP FIRST-WHY?
 BEST FELT BY BACK OF THE HAND-WHY?
 I...
2.TENDERNESS

 PAIN DUE TO PRESSURE EXERTED OVER
  THE SWELLING IS TENDERNESS
 PALPATE GENTLY OVER ALL THE AREA
 IT IS ...
3.SIZE& SHAPE
 CONFIRM VERTICAL & HORIZONTAL
 DIMENSIONS

 NOTE THE THIRD DIMENSION DEPTH
 WHICH COULD NOT BE EXACTLY
 D...
4.SURFACE
 WITH PALMAR SURFACE
  SMOOTH –CYSTIC SWELLINGS
  LOBULARWITH SMOOTH BUMPS-LIPOMA
  NODULAR –MULTI NODULAR G...
SMOOTH SURFACE OF A SEBACEOUS CYST




*Image via Bing
*Image via Bing
M..N.G. WITH NODULAR SURFACE
5.EDGE
 1)WELL DEFINED & REGULAR – BENIGN
 NEOPLASMS

 2)WELL DEFINED & IRREGULAR –
 MALIGNANT NEOPLASM

 3)ILLDEFINED ...
ABSCESS WITH ILL DEFINED MARGINS




*Image by 9085776@N08 via Flickr
LIPOMA WOTH WELL DEFINED MARGINS




*Image by 72310117@N07 via Flickr
LARGE LIPOMA WITH WELL DEFINED MARGINS




    *Image by 78523246@N00 via Flickr
*Image by 78523246@N00 via Flickr
IRREGULAR BORDERS IN CARCINOMA BREAST




*Image via Bing
SLIP SIGN


                             *Image via Bing

 TO DEFFERENTIATE BETWEEN LIPOMA
  AND CYSTIC SWELLING(BOTH HAV...
6.CONSISTENCY

 SOFT – LIPOMA
 CYSTIC- CYSTS &CHRONIC ABSCESSES
 FIRM –FIBROMA
 HARD BUT YIELDING-CHONDROMA
 BONY HAR...
HOW TO ASSESS CONSISTENCY

 SOFT – EAR LOBULE,ALAE OF NOSE


 FIRM- TIP OF NOSE,UN CONTRACTED
 MUSCLE

 HARD -BRIDGE OF...
SIGN OF MOULDING OR
INDENTATION
 LOOK FOR THIS SIGN IN SOFT &CYSTIC
 SWELLINGS
   PRESS A FINGER INTO SWELLING FOR 1-2 M...
PAGET’S TEST

 DONE FOR SMALL SWELLINGS TO KNOW
  THE CONSISTENCY(CYSTIC/SOLID)
 THE CENTRE AND PERIPHERIES ARE
  PALPAT...
SPECIAL TESTS

 DONE IN CASE OF SOFT/CYSTIC SWELLING
  7.FLUCTUATION
  8.TRANSILLUMINATION
  9.COUGH IMPULSE
  10.RED...
7.FLUCTUATION


 TRANSMISSION OF IMPULSE IN TWO
  DIRECTIONS AT RIGHT ANGLES TO EACH
  OTHER
 IMPLIES PRSENCE OF FLUID I...
HOW TO ELICIT FLUCTUATION?

 IF THE SWELLING IS MOBILE FIRST FIX IT OR
    ASK THE ASST. TO HOLD IT
   KEEP 2 INDEX FING...
LAW BEHIND FLUCTUATION!

 PASCAL’S LAW
  PRESSURE EXERTED TOA FLUID IS TRANSMITTED
      EQUALLY IN ALL THE DIRECTIONS

...
PRINCIPLES WHILE DOING FLUCTUATION
TEST

 ALWAYS PERFORM IN 2 DIRECTIONS AT
    RIGHT ANGLES TO EACH OTHER
   TWO FINGER...
PSEUDO FLUCTUATION

 A FALSE SENSE OF FLUCTUATION FELT IN
  LARGE SOFT SWELLINGS CONTAINING NO
  FLUID
 SEEN IN
     LA...
CROSS FLUCTUATION

 FLUCTUATION BETWEEN TWO SEPARATE
  CYSTIC SWELLINGS COMMUNICATING
  WITH EACH OTHER
 SEEN IN
  COMP...
8.TRANSILLUMINATION

 DEMONSTRATION OF TRANSMISSION OF
  LIGHT THROUGH A SWELLING
 POSITIVE IN SWELLINGS CONTAINING
  CL...
BRILLIANTLY TRANSILLUMINANT SWELLINGS


 1.CYSTIC HYGROMA

 2.EPIDIDYMAL CYST

 3.MENINGOCELE WITH THIN SKIN

 4.RANUL...
9.COUGH IMPULSE

 PERFORMED IN SWELLINGS LIKELY TO BE
  IN CONTACT WITH ABDOMINAL
  ,CRANIAL ,SPINAL OR CHEST CAVITY
 SW...
SWELLINGS WITH POSITIVE COUGH IMPULSE


 IN CONTINUITY WITH ABD. CAVITY
   HERNIA
   ILIO-PSOAS ABSCSS
   LUMBAR ABSCE...
10.REDUCIBILITY

 INDICATION SAME AS FOR COUGH
  IMPULSE
 PATIENT IS ASKED TO RELAX
 SWELLING IS COMPRESSED FROM ALL TH...
REDUCIBLE SWELLINGS

 1.HERNIA
 2.MENINGOCELE
 3.VARICOCELE
 4.SAPHENA VARIX
  A REDUCIBLE SWELLING ONCE REDUCED
   R...
11.COMPRESSIBILITY

 WHEN PRESSURE IS APPLIED TO A
 SWELLING IT DECREASES IN SIZE AND
 WHEN PRESSURE IS RELEASED SWELLING...
12.PULSATILITY

 WHEN FINGER IS PLACED OVER A
  PULSATILE SWELLING IT RAISESWITH
  EACH BEAT
 TO TYPES OF PULSATIONS
  ...
HOW TO DIFFERENTIATE?

 TWO FINGERS ARE PLACED OVER THE
  SWELLING AND FINGER MOVEMENTS ARE
  NOTED
 TRANSMITTED PULSATI...
IN AN ABDOMINAL LUMP?

 KNEE ELBOW POSITION
  WHEN KEPT IN KNEE ELBOW POSITION


    PULSATIONS DISAPPEAR – TRANSMITTED...
13.FIXITY TO SKIN

 SKIN PINCHED OVER DIFFERENT PARTS OF
  THE SWELLING -CANNOT BE PINCHED IF
  FIXED TO SKIN
 SKIN IS M...
14.RELATION TO SURROUNDING STRUCTURES


 1)SUBCUTANEOUS TISSUE
   SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT
    ADHERENT...
3)RELATION TO MUSCLE

 RELATION SHIP TO MUSCLE IS KNOWN BY
 THROWING THE CONCERNED MUSCLE
 INTO CONTRACTION
  TUMOURS IN...
4)SWELLING IN RELATION TO TENDON
 MOVES ALONG WITH TENDON&BECOMES
    FIXED WHEN MUSCLE CONTRACTS
   5)IN CONNECTION WIT...
PERCUSSION

 LIMITED VALUE IN SWELLINGS
  1.TYMPANIC NOTE
    ENTEROCELE
    PHARYNGOCELE

  2.HYDATID THRILL
    HY...
AUSCULTATION

 BRUIT OVER PULSATILE &VASCULAR
  SWELLINGS
 BRUIT
  SHORT,MEDIUM PITCHED MURMUR HEARD
   OVER THE SWELLI...
REGIONAL LYMPH NODES

 DRAINING LYMPH NODES EXAMINED IF
  INVOLVED NEXT HIGHER GROUP EXAMINED
 IF THE SWELLING ITSELF IS...
PRESSURE EFFECTS

 1.OVER BONE – FEEL FOR BONY EROSION
   AS IN DERMOID CYST
 2.IN LIMBS
   DISTAL PULSES- PRESSURE OV...
WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE




     *Image via Bing
SPINAL LIPOMA




*Image via Bing
GENERAL EXAMINATION
Question time?
 WHAT IS UNIVARSAL TUMOUR?
 WHAT ARE THE PROCESSESS FUSING IN
    EXTERNAL ANGULAR DERMOID?
   WHAT IS T...
THANKS FOR PATIENT LISTENING

*Image by 40501877@N04 via Flickr
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Clinical examination of swelling

  1. 1. POWER POINT CLINICS
  2. 2. DR.M.RAVI CHANDRA,M.S(G.S) ASST. PROF. OF SURGERY RIMS SRIKAKULAM
  3. 3. INSPECTION  1. SITE- EXACT ANATOMICAL LOCATION IMPORTANT AS SOME SWELLINGS OCCUR IN A TYPICAL POSITION WHICH IS DIAGNOSTIC  EXAMPLES  POST AURICULAR DERMOID-BEHIND EAR  EXTERNAL ANGULAR DERMOID –LATERAL END OF EYE BROW  MENINGOCELE- OVER THE BACK IN MIDLINE
  4. 4. EXTERNAL ANGULAR DERMOID *Image via Bing
  5. 5. EXTERNAL ANGULAR DERMOID *Image via Bing
  6. 6. *Image via Bing
  7. 7. SUB MANDIBULAR DERMOID *Image by 12498905@N02 via Flickr
  8. 8. *Image by 48276084@N00 via Flickr
  9. 9. DERMOID CYST OF SCALP *Image via Bing
  10. 10. DERMOID CYST IN MID LINE *Image via Bing
  11. 11. ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW *Image via Bing
  12. 12. *Image via Bing
  13. 13. MENINGOCELE *Image via Bing
  14. 14. HUMAN TAIL? *Image via Bing
  15. 15. 2.NUMBER  USUALLY SINGLE , SOME TIMES MULTIPLE  MULTIPLE EXAMPLES  MULTIPLE NEUROFIBROMATOSIS(VON RECK LING HAUSENS DISEASE)  MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)  DIAPHYSEAL ACLASIS  HYDRADENITIS SUPPURATIVA  MULTIPLE LYMPHOGLANDULAR SWELLINGS
  16. 16. *Image via Bing
  17. 17. *Image via Bing
  18. 18. MULTIPLE LIPAMATOSIS *Image via Bing
  19. 19. HYDREDENITIS SUPPURATIVA OF AXILLA *Image via Bing
  20. 20. *Image via Bing
  21. 21. *Image via Bing
  22. 22. EXTEXNSIVE SCARRING UNDER THE ARMS DUE TO HYDREDENITIS SUPPURATIVA *Image via Bing
  23. 23. 3.SHAPE  SPHERICAL  OVOID  KIDNEY /BEAN SHAPED/RENIFORM  IRREGULAR
  24. 24. 4.SIZE
  25. 25. 5.SURFACE  COLOUR  SPECIAL CHARACTER OF SURFACE  OVERLYING SKIN
  26. 26. A)COLOUR  ARTERIAL HAEMANGIOMA – BRIGHT RED  VENOUS HAEMANGIOMA— PURPLE  MALIGNANT MELANOMA- BLACK  BENIGN NAEVUS – BLACK  RANULA –BLUE
  27. 27. CAPILLARY HAEMANGIOMA OVER FORE HEAD *Image via Bing
  28. 28. BENIGN NEVUS
  29. 29. BENIGN NEVUS *Image via Bing
  30. 30. HERIDITARY DYSPLASTIC NAEVUS SYNDROME *Image via Bing
  31. 31. *Image via Bing
  32. 32. MALIGNANT MELANOMA *Image via Bing
  33. 33. *Image via Bing
  34. 34. MALIGNANT MELANOMA OF FOOT *Image via Bing
  35. 35. RANULA *Image via Bing
  36. 36. *Image via Bing
  37. 37. RANULA OF RIGHT SUBLINGUAL *Image via Bing
  38. 38. b)Character of surface  TWO CHARACTERISTIC SURFACES ON INSPECTION  CAULIFLOWER SURFACE – SQUAMOUS CELL CARCINOMA  FILIFORM BRANCHED SURFACE – PAPILLOMA (IRREGULAR NUMEROUS BRANCHED SURFACE)
  39. 39. SQUAMOUS CELL CARCINOMA *Image via Bing
  40. 40. *Image via Bing
  41. 41. SCC OF TONGUE *Image via Bing
  42. 42. FILIFORM SURFACE OF PAPILLOMA *Image via Bing
  43. 43. INDONESIAN TREE MAN *Image via Bing H.P.V. AFFECTING HANDS &LEGS
  44. 44. c)Skin over lying swelling  TENSE , SHINY WITH PROMINENT VEINS – SARCOMA  RED &EDEMATOUS – INFLAMMATORY  BLACK PUNCTUM – SEBACEOUS CYST  PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS  SCAR  PREVIOUS OPERATION(REGULAR SCAR WITH SUTURE MARKS)  INJURY(REGULAR SCAR)  SUPPURATION(PUCKERED ,BROAD &IRREGULAR)  PEAU - D ORANGE APPEARANCE(MAINLY IN CA. BREAST)  ULCERS
  45. 45. ABSCESS *Image via Bing
  46. 46. ABDOMINAL WALL ABSCESS *Image via Bing
  47. 47. NASAL ABSCESS *Image via Bing
  48. 48. INFECTED SEBACEOUS CYST WITH PUNCTUM *Image via Bing
  49. 49. SOFT TISSUE SARCOMA *Image via Bing
  50. 50. *Image by 88761406@N00 via Flickr
  51. 51. *Image via Bing
  52. 52. 6.VISIBLE PULSATIONS  PULSATION  A MOVEMENT OR INCREASE IN SIZE SYNCHRONOUS WITH EACH HEART BEAT  2 TYPES  EXPANSILE PULSATIONS – SWELLINGS ARISING FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID BODY TUMOUR  TRANSIMITTED PULSATIONS – SWELLINGS CLOSE TO ARTERIES  REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION
  53. 53. 7.VISIBLE COUGH IMPULSE  PERFORMED WHEN SWELLING IS OVER ABDOMEN,CHEST,SPINAL CANAL OR CRANIUM  COUGH IMPULSE  VISIBLE INCREASE IN THE SIZE OF SWELLING SYNCHRONOUS WITH COUGH  POSITIVE IN SWELLINGS COMMUNICATING WITH ABDOMEN,THORACIC CAVITY,SPINAL CANAL OR CRANIAL CAVITY
  54. 54. POSITIVE COUGH IMPULSE  HERNIA  MENINGOCELE  VARICOCELE  SAPHENA VARIX  IN CHILDREN CRYING ACTS AS COUGHING
  55. 55. 8.VISIBLE PERISTALYSIS  OBSERVED IN ABDOMINAL LUMPS AND INGUINAL SWELLINGS  CONGENITAL HYPERTROPHIC PYLORIC STENOSIS – VISIBLE GASTRIC PERISTALYSIS  INGUINAL HERNIAS (ENTEROCELE) INTESTINAL PERISTALYSIS  LUMPS DUE TO INTESTINAL MALIGNANCY PERISTALYSIS IS SEEN
  56. 56. 9.MOVEMENT WITH RESPIRATION  SEEN IN ABDOMINAL LUMPS  SWELLINGS ARISING FROM  STOMACH  LIVER  SPLEEN  GALLBLADDER  HEPATIC FLEXURE OF COLON  SPLENIC FLEXURE OF COLON  RENAL LUMP THOUGH NOT IN CONTACT WITH DIAPHRAGM ,MOVES WITH RESPIRATION
  57. 57. 10.Movement with deglutition  IN CASE OF NECK SWELLINGS  SWELLINGS MOVING WITH DEGLUTITION  THYROID SWELLING  THYROGLOSSAL CYST  THYROGLOSSAL FISTULA  SUBHYOID BURSA  PRE/PARA TRACHEAL LYMPH NODES  EXTRINSIC CARCINOMA OF LARYNX
  58. 58. WHY THYROID MOVES UP WITH DEGLUTITION?  THYROID IS ENCLOSED IN PRETRACHEAL FASCIA  PTF ATTACHES TO THYROID &CRICOID CARTILAGES(BERRY’S LIGAMENT)  SUPERIOR CONSTRICTOR MUSCLE CONTRACTION DURING DEGLUTITION  THESE CARTILAGES MOVE UP  ALONG WITH THESE THYROID MOVES UP
  59. 59. 11)MOVEMENT WITH TONGUE PROTRUSION  IN CASE OF MID LINE NECK SWELLINGS  EG:THYROGLOSSAL CYST &FISTULA  WHY?  ATTACHED TO FORAMEN CAECUM OF TONGUE
  60. 60. 12)PRESSURE EFFECTS  WHEN SWELLING IS PRESENT ON LIMBS  AN AXILLARY SWELLING WITH LIMB EDEMA – LYMPHNODAL SWELLING  PARESIS – PRESSURE ON NERVES  WASTING OF MUSCLES OF DISTAL LIMB- TRAUMATIC SWELLING(WASTING DUE TO NON-USE/INJURY TO NERVES)  SWELLING IN NECK WITH VENOUS ENGORGEMENT(RETROSTERNAL EXTENSION)
  61. 61. PALPATION  DEFINITE CLUE TO DIAGNOSIS  METHODICAL,FOLLOW DEFINITE ORDER  BE GENTLE  SHOULD NOT HURT THE PT.
  62. 62. 1.TEMPERATURE  IT IS AN ABSOLUTE STANDARD PRACTICE TO TEST FOR TEMP FIRST-WHY?  BEST FELT BY BACK OF THE HAND-WHY?  INCREASED IN  INFLAMMATORY SWELLING  WELL VASCULARISED TUMOURS- SARCOMA
  63. 63. 2.TENDERNESS  PAIN DUE TO PRESSURE EXERTED OVER THE SWELLING IS TENDERNESS  PALPATE GENTLY OVER ALL THE AREA  IT IS A SIGN  FEATURE OF  INFLAMMATORY SWELLINGS  SWELLING RELATED TO NERVES -NEUROFIBROMA
  64. 64. 3.SIZE& SHAPE  CONFIRM VERTICAL & HORIZONTAL DIMENSIONS  NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION
  65. 65. 4.SURFACE  WITH PALMAR SURFACE  SMOOTH –CYSTIC SWELLINGS  LOBULARWITH SMOOTH BUMPS-LIPOMA  NODULAR –MULTI NODULAR GOITRE/MATTED LYMPH NODES  IRREGULAR - CARCINOMA
  66. 66. SMOOTH SURFACE OF A SEBACEOUS CYST *Image via Bing
  67. 67. *Image via Bing
  68. 68. M..N.G. WITH NODULAR SURFACE
  69. 69. 5.EDGE  1)WELL DEFINED & REGULAR – BENIGN NEOPLASMS  2)WELL DEFINED & IRREGULAR – MALIGNANT NEOPLASM  3)ILLDEFINED &DIFFUSE –INFLAMMATORY SWELLINGS
  70. 70. ABSCESS WITH ILL DEFINED MARGINS *Image by 9085776@N08 via Flickr
  71. 71. LIPOMA WOTH WELL DEFINED MARGINS *Image by 72310117@N07 via Flickr
  72. 72. LARGE LIPOMA WITH WELL DEFINED MARGINS *Image by 78523246@N00 via Flickr
  73. 73. *Image by 78523246@N00 via Flickr
  74. 74. IRREGULAR BORDERS IN CARCINOMA BREAST *Image via Bing
  75. 75. SLIP SIGN *Image via Bing  TO DEFFERENTIATE BETWEEN LIPOMA AND CYSTIC SWELLING(BOTH HAVE WELL DEFINED ,REGULAR BORDERS)  WHEN EDGE OF A SWELLING IS PALPATED WITH A FINGER ,IF IT SLIPS UNDER THE FINGER,. DOES NOT YIELD TO IT , IT IS A LIPOMA,IF IT YIELDS TO FINGER IS A CYST
  76. 76. 6.CONSISTENCY  SOFT – LIPOMA  CYSTIC- CYSTS &CHRONIC ABSCESSES  FIRM –FIBROMA  HARD BUT YIELDING-CHONDROMA  BONY HARD-OSTEOMA  STONY HARD- CARCINOMA  VARIABLE CONSISTENCY- MALIGNANCY
  77. 77. HOW TO ASSESS CONSISTENCY  SOFT – EAR LOBULE,ALAE OF NOSE  FIRM- TIP OF NOSE,UN CONTRACTED MUSCLE  HARD -BRIDGE OF NOSE,CONTRACTED MUSCLE
  78. 78. SIGN OF MOULDING OR INDENTATION  LOOK FOR THIS SIGN IN SOFT &CYSTIC SWELLINGS  PRESS A FINGER INTO SWELLING FOR 1-2 MTS AND RELEASE IT IF SWELLING REMAINS INDENTED IT INDICATES PRESENCE OF PULTACEOUS MATERIAL(PUTTY LIKE)  SEEN IN  1.SEBACYOUS CYST  2.DERMOID CYST  3.COLONIC MASS WITH FAECAL MATTER
  79. 79. PAGET’S TEST  DONE FOR SMALL SWELLINGS TO KNOW THE CONSISTENCY(CYSTIC/SOLID)  THE CENTRE AND PERIPHERIES ARE PALPATED WITH INDEX FINGER  CYSTIC SWELLING FEELS SOFTER AT CENTRE THAN PARIPHERY  SOLID SWELLING FEELS FIRMER ATCENTRE THAN PERIPHERY
  80. 80. SPECIAL TESTS  DONE IN CASE OF SOFT/CYSTIC SWELLING  7.FLUCTUATION  8.TRANSILLUMINATION  9.COUGH IMPULSE  10.REDUCIBILITY  11.COMPRESSIBILITY  IN SOLID SWELLINGS DIRECTLY PROCEED TO TEST FOR RELATION TO OTHER STRUCTURES
  81. 81. 7.FLUCTUATION  TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER  IMPLIES PRSENCE OF FLUID IN THE SWELLING
  82. 82. HOW TO ELICIT FLUCTUATION?  IF THE SWELLING IS MOBILE FIRST FIX IT OR ASK THE ASST. TO HOLD IT  KEEP 2 INDEX FINGERS ON OPPOSITE POLES  WHEN ONE FINGER IS PRESSED THE FINGER AT OPPOSITE END FEELS THE IMPULSE & PASSIVELY LIFTED UP  REPEAT THE MANUVERE IN A PLANE AT RIGHT ANGLES TO THE 1ST ONE  IF IMPULSE IS FELT IN BOTH PLANES IT IS A POSITIVE FLUCTUATION TEST
  83. 83. LAW BEHIND FLUCTUATION!  PASCAL’S LAW  PRESSURE EXERTED TOA FLUID IS TRANSMITTED EQUALLY IN ALL THE DIRECTIONS *Image via Bing
  84. 84. PRINCIPLES WHILE DOING FLUCTUATION TEST  ALWAYS PERFORM IN 2 DIRECTIONS AT RIGHT ANGLES TO EACH OTHER  TWO FINGERS SHOULD BE KEPT AS FAR APART AS POSSIBLE  FREELY MOBILE SWELLINGS SHOULD BE FIXED FIRST(AS IN HYDROCELE)  SMALL SWELLINGS –WATCHING FINGER & DISPLACING FINGER  VERY LARGE SWELLINGS MORE THAN ONE FINGFR SHOLD BE USED
  85. 85. PSEUDO FLUCTUATION  A FALSE SENSE OF FLUCTUATION FELT IN LARGE SOFT SWELLINGS CONTAINING NO FLUID  SEEN IN  LARGE LIPOMA  MYXOMA  SOFT FIBROMA  VASCULAR SARCOMA  FAIL TO EXPAND IN OTHER PARTS OF A SWELLING LIKE A TRUE FLUCTUANT SWELLING
  86. 86. CROSS FLUCTUATION  FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER  SEEN IN  COMPOUND PALMAR GANGLION  PSOAS ABSCESS  PLUNGING RANULA
  87. 87. 8.TRANSILLUMINATION  DEMONSTRATION OF TRANSMISSION OF LIGHT THROUGH A SWELLING  POSITIVE IN SWELLINGS CONTAINING CLEAR FLUID AND THIN TRANSPARENT WALLS  NO TRANSILLUMINATION IF WALL IS THICK, OR TURBID FLUID IS PRESENT(BLOOD,PUS, LYMPH)  DARK ROOM , TRANSILLUMINOSCOPE
  88. 88. BRILLIANTLY TRANSILLUMINANT SWELLINGS  1.CYSTIC HYGROMA  2.EPIDIDYMAL CYST  3.MENINGOCELE WITH THIN SKIN  4.RANULA  5.CONGENITAL HYDROCELE
  89. 89. 9.COUGH IMPULSE  PERFORMED IN SWELLINGS LIKELY TO BE IN CONTACT WITH ABDOMINAL ,CRANIAL ,SPINAL OR CHEST CAVITY  SWELLING IS HELD WITH FINGERS AND PATIENT IS ASKED TO COUGH  IF THE SWELLING BECOMES TENSE OR INCREASES IN SIZE IT IS POSITIVE COUGH IMPULSE  IN CHILDREN CRYING ACTS AS COUGH
  90. 90. SWELLINGS WITH POSITIVE COUGH IMPULSE  IN CONTINUITY WITH ABD. CAVITY  HERNIA  ILIO-PSOAS ABSCSS  LUMBAR ABSCESS  IN CONTINUITY WITH PLEURAL CAVITY  EMPYEMA NECESSITANS  IN CONTINUITY WITH SPINAL /CRANIAL CAVITY  SPINAL/CRANIAL MENINGOCELE
  91. 91. 10.REDUCIBILITY  INDICATION SAME AS FOR COUGH IMPULSE  PATIENT IS ASKED TO RELAX  SWELLING IS COMPRESSED FROM ALL THE SIDES UNIFORMLY  REDUCIBLE SWELLINGS DECREASESIN SIZE OR COMLETELY DISAPPEAR
  92. 92. REDUCIBLE SWELLINGS  1.HERNIA  2.MENINGOCELE  3.VARICOCELE  4.SAPHENA VARIX  A REDUCIBLE SWELLING ONCE REDUCED REAPPEARS ONLY BY STRAINING,COUGHING, OR FORCE OF GRAVITY AS IT INVOLVES DISPLACEMENT OF VISCERS TO AN ADJOINING CAVITY
  93. 93. 11.COMPRESSIBILITY  WHEN PRESSURE IS APPLIED TO A SWELLING IT DECREASES IN SIZE AND WHEN PRESSURE IS RELEASED SWELLING REGAINS ITS SIZE ITSELF WITH OUT ANY EXTERNAL FACTORLIKE STRAINING OR COUGHING  CHARECTARISTIC SIGN OF VASCULAR HAEMANGIOMA
  94. 94. 12.PULSATILITY  WHEN FINGER IS PLACED OVER A PULSATILE SWELLING IT RAISESWITH EACH BEAT  TO TYPES OF PULSATIONS  TRANSMITTED PULSATIONS- SEEN IN SWELLINGS PRESENT NEAR AN ARTERY  EX:CA STOMACH LUMP NEAR ABD.AORTA  EXPANSILE PULSATIONS-SEEN IN SWELLINGS ARISING FROM ARTERIES  EX:AORTIC ANEURYSM
  95. 95. HOW TO DIFFERENTIATE?  TWO FINGERS ARE PLACED OVER THE SWELLING AND FINGER MOVEMENTS ARE NOTED  TRANSMITTED PULSATIONS – FINGERS ARE SIMPLY LIFTED UP  EXPANSILE PULSATIONS- FINGERS ARE LIFTED UP AND MOVE APART
  96. 96. IN AN ABDOMINAL LUMP?  KNEE ELBOW POSITION  WHEN KEPT IN KNEE ELBOW POSITION  PULSATIONS DISAPPEAR – TRANSMITTED PULSATIONS  PULSATIONS PERSIST –EXPANSILE PULSATIONS
  97. 97. 13.FIXITY TO SKIN  SKIN PINCHED OVER DIFFERENT PARTS OF THE SWELLING -CANNOT BE PINCHED IF FIXED TO SKIN  SKIN IS MADE TO MOVE OVER THE SWELLING- THE SKIN WILL NOT MOVE IF IT IS FIXED TO SKIN  SWELLINGS ARISING FROM SKIN ARE FIXED TO SKIN EX:SEBACEOUS CYST , PAPILLOMA , EPITHELIOMA
  98. 98. 14.RELATION TO SURROUNDING STRUCTURES  1)SUBCUTANEOUS TISSUE  SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT ADHERENT TO SKIN OR UNDERLYING MUSCLE  LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN SOME PLACES – DUE PRESENCE OF FIBROUS SEPTA  2)DEEP FASCIA  SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS MOBILE AS SUBCUTANEOUS SWELLINGS  IT IS DIFFICULT MAKE OUT FIXATION TO DEEP FASCIA AS DEEP FASCIA CANNOT BE MADE TAUT  EVEN IF TUMOUR IS ATTACHED TO UNDERLYING DEEP FASCIA &MUSCLE TUMOUR CAN BE MOVED SIDEWAYS
  99. 99. 3)RELATION TO MUSCLE  RELATION SHIP TO MUSCLE IS KNOWN BY THROWING THE CONCERNED MUSCLE INTO CONTRACTION  TUMOURS IN SUB CUTANEOUS TISSUE- BECOME MORE PROMINENT &REMAIN MOBILE  TUMOURS ARISING FROM MUSCLE / INCORPORATED IN MUSCLE-FIXED&IMMOBILE  TUMORS DEEP TO MUSCLE –LESS PROMINENT, OR DISAPPEARS,DIFFICULT TO PALPATE
  100. 100. 4)SWELLING IN RELATION TO TENDON  MOVES ALONG WITH TENDON&BECOMES FIXED WHEN MUSCLE CONTRACTS  5)IN CONNECTION WITH VESSELS &NERVES  DO NOT MOVE ALONG VESSELS OR NERVES BUT MOVE TO A LITTLE EXTENT AT RIGHT ANGLES TO THEIR AXES  6)IN CONNECTION WITH BONE  IS ABSOLUTELY FIXED IRRESPECTIVE OF MUSCLE CONTRACTION
  101. 101. PERCUSSION  LIMITED VALUE IN SWELLINGS  1.TYMPANIC NOTE  ENTEROCELE  PHARYNGOCELE  2.HYDATID THRILL  HYDATID CYST
  102. 102. AUSCULTATION  BRUIT OVER PULSATILE &VASCULAR SWELLINGS  BRUIT  SHORT,MEDIUM PITCHED MURMUR HEARD OVER THE SWELLING WITH EACH PULSE WAVE  EX:ANEURYSM  THYROTOXIC GOITRE
  103. 103. REGIONAL LYMPH NODES  DRAINING LYMPH NODES EXAMINED IF INVOLVED NEXT HIGHER GROUP EXAMINED  IF THE SWELLING ITSELF IS ALYMPH NODE EXAMINE  1.OTHER LYMPH NODAL GROUPS  2.SPLEEN  3.LIVER  TO EXCLUDE SYSTEMIC CAUSE  EXAMINE DRAINAGE AREA TO EXCLUDE INFECTION
  104. 104. PRESSURE EFFECTS  1.OVER BONE – FEEL FOR BONY EROSION  AS IN DERMOID CYST  2.IN LIMBS  DISTAL PULSES- PRESSURE OVER ARTERIES  EDEMA &DILATED VEINS – PRESSURE OVER VEINS  PARESIS& MUSCLE WASTING – PRESSURE OVER NERVES  MOVEMENTS OF JOINTS
  105. 105. WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE *Image via Bing
  106. 106. SPINAL LIPOMA *Image via Bing
  107. 107. GENERAL EXAMINATION
  108. 108. Question time?  WHAT IS UNIVARSAL TUMOUR?  WHAT ARE THE PROCESSESS FUSING IN EXTERNAL ANGULAR DERMOID?  WHAT IS THE TUMOUR SHOWING POSITIVE SLIP SIGN?  WHAT IS THE SITE AT WHICH A LIPOMA MOST COMMONLY UNDERGOES SARCOMATOUS CHANGE?  WHAT IS THE MOST COMMON SITE FOR CYSTIC HYGROMA?  WHAT IS THE OTHER NAME FOR BASAL CELL CARCINOMA?
  109. 109. THANKS FOR PATIENT LISTENING *Image by 40501877@N04 via Flickr
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