Transcript
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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1xamination o' an ulcerK. 1dge 5 (epth@
Healing ulcer
Cenous ulcer can have it
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1xamination o' an ulcerK. 1dge 5 (epth@
Trophic ulcer
Neuropathy L (+
Arterial ischemia
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1xamination o' an ulcerK. 1dge 5 (epth@
ressure necrosissub! 'at is more susceptible to pressure than
the skin
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1xamination o' an ulcerK. 1dge 5 (epth@
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 structure@e.g.+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
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