Clinical
examination
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
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.
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.
Ulcers
are of five main varieties:
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
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.
Fluctuation is 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