Year 2 MBChB Clinical Skills Session Examination of swellings

Transcription

1 Year 2 MBChB Clinical Skills Sessin Examinatin f swellings

2 Learning bjectives. T be able t systematically examine and describe the characteristics f a swelling T understand the difference between a true and false swelling T be able t dcument yur findings Thery and backgrund. The presentatin f lumps, swellings r masses is a cmmn clinical situatin: e.g. breast lump, swllen ankles r a mass fund n rectal examinatin. Mst swellings can be described by a number f cmmn characteristics e.g. size, shape, psitin etc. Hwever, there are a number f characteristics that cannt in all cases be described e.g. the appearance and clur f the verlying skin can be described if examining a breast lump, but nt if it is a mass fund in the rectum. This guide cvers the examinatin f generic swellings, but please lk at the individual study guides fr details f specific (rectal, bimanual, breast etc) examinatins. Overview f swellings descriptrs When examining and describing swellings it has a mdified versin f inspectin etc which is as fllws Inspectin, Initial palpatin and then Palpatin. In terms f an verview a swelling can be described using the fllwing descriptrs; Inspectin Psitin Overlying skin Initial palpatin Pulsatin Tenderness Palpatin Mbility Shape Surface Edge Cnsistency Depth Indentatin Fluctuatin Temperature Size Transilluminatin The abve adjectives will be expanded n as yu prceed thrugh this study guide. Terminlgy D nt cnfuse pain with tenderness. The patient may have cmplained f pain in their histry this wuld be classed as a symptm. Whereas, tenderness is a sign that is detected during the examinatin. 2

3 Patient safety. On first meeting a patient intrduce yurself, cnfirm that yu have the crrect patient with the name and date f birth, if available please check this with the name band and written dcumentatin and the NHS/ hspital number/ first line f address. Check the patient s allergy status, being aware f the equipment yu will be using in yur examinatin. Ensure the prcedure is explained t the patient in terms that they understand, gain infrmed cnsent and ensure that yu are supervised, with a chaperne available as apprpriate. Dn persnal prtective equipment as required, especially if yu are likely t cme int cntact with bdily fluids. Be aware f hand hygiene and preventing the spread f disease, WHO (2018) This prcedure may require the presence f a chaperne. That is smene wh is familiar with the examinatin and can ensure that nthing inapprpriate ccurs by either party. The chaperne can be a useful resurce, nt just being present t ensure the patient is treated apprpriately, but t help and supprt the patient. Prcedure. Inspectin f the swelling Inspect the patient frm the end f the bed r when yu first bserve them and nte any indicatin f pain, their gait and any ther features that may deviate frm the nrm. On clser bservatin ensure the patient s dignity is maintained and expse as much as is necessary. Observable features t nte; Psitin Describe the psitin in detail. Fr example A swelling was bserved n the anterir aspect f the frearm, 10cm distal t the antecubital fssa. Because writing There is a swelling just belw the inside n the elbw carries insufficient precisin f infrmatin. The text that yu write can be reinfrced by a drawing denting what yu have written. 3

4 Overlying skin; Where pssible inspect the verlying skin f the swelling nting the clur f the swelling as well as that f the surrunding skin. Nte if there is any bleeding r evidence f sepsis (pus) Nte if the skin is intact r brken. There may be bvius puncture marks indicating an insect bite. Palpatin When palpating yu may detect that the swelling is pulsating, this may als be bserved n inspectin. Hwever, yu will need t palpate t determine the rigin f the pulsatin and whether it is tender r nt. Psitin yur hands n each side f the swelling, s that yur index fingers are gently resting n each side f the swelling, nte whether the mass feels pulsatile. If the swelling is pulsatile, it may suggest an aneurysm (which may rupture if the examinatin is t rigrus). If pulsatin is felt; des it feel as if the pulsatin is in all directins ( true pulsatin ) r simply up and dwn ( false pulsatin )? If the mass is pulsatile, stp examining and ask a senir clleague t review the patient. True pulsatin This is ptentially the mre serius cnditin as it means the swelling is in the wall f an artery i.e. an aneurysm. The nature f true pulsatin is that the pulsatin takes places in all directins f the vessel simultaneusly. False pulsatin Occurs nly up and dwn; the mass sits n tp f the artery, but des nt distend utwards as it des nt transmit the pressure wave caused by the flw f bld Tenderness When palpating the swelling bserve the patient t nte any signs f tenderness. If any tenderness is exhibited, then care must be taken in hw yu palpate t avid further discmfrt. If it is s tender, yu may have t ffer analgesia (pain relief) befre carrying n with the exam. The presence f tenderness may give yu a clue as t the cause f the swelling. e.g. an abscess. 4

5 S far in the examinatin f a swelling we have lked at; Psitin Overlying the skin Pulsatin Tenderness A simple mnemnic t help remember these factrs is: Pupils Only Play Tennis. Shape Describe the shape. Yu may wish t use the fllwing adjectives; spherical elliptical irregular shape vid Surface Nte what the surface texture f the swelling feels like and describe it as; rugh smth granular ndular Edge Fllwing n frm describing the surface, describe the edge r the brders f the swelling. Yu may wish t describe as fllws; Clearly defined edge. Clearly defined edge with ndules. If the edges are nt clearly defined and yu cannt determine the edges r the brder f the swelling yu wuld describe it as Diffuse. Describe as fllws; Diffuse edge. Edge diffuse. An example f why a swelling may be diffuse is edema, s causing the edges t be diffuse r blurred. Cnsistency When yu have palpated yu may have nted and described the surface f the swelling, but hw des it feel? Yu may wish t describe it as fllws; It is hard. It is firm. It is sft. It is bggy. 5

6 Depth Swellings can be classed as either deep r superficial and this may indicate the rigin f the swelling. Fr dcumentatin purpses yu may describe the swelling as a superficial swelling r a deep swelling. This is nt a measurement f the height f the swelling but as described, its rigin. Fr example; A rectal mass wuld be classed as a deep swelling. An insect bite n a finger that caused a swelling wuld be described as superficial. Indenting f the swelling Apply gentle pressure t the surface f the swelling with yur examining index finger and nte if there is a depressin left n the surface f the swelling upn withdrawal. If there is then it can be described as indentable. NOTE: If the swelling indents when yu press, but springs back when yur finger is remved, this IS NOT indentatin. WARNING - d nt try t indent a pulsating swelling. Fluctuance A swelling can be classed as either fluctuant r nn-fluctuant. Fluctuance is where the swelling may cntain fluid within and f varying viscsity. The fluid within the swelling can cause the fluid t mve if pressure is exerted at specific pints n the swelling s surface. In ther wrds is it squidgy? This fluid may be clear r paque e.g. bld r pus. In rder t test fr this yu may d the fllwing; Tw digits are placed either side f the apex f the swelling. Pressure is applied t the apex. This is repeated with the digits at 90. The finding is psitive if the tw digits are pushed away in bth directins. If a swelling is fluctuant, it suggests the presence f fluid within the swelling. Temperature If the swelling is superficial and has a red angry appearance suggestive f infectin, yu may want t assess the temperature f the swelling by hlding the drsum (back) f yur hand abve its surface. Then cmpare that temperature t that f the surrunding tissues. Dcument whether the swelling was; ht warm cld n temperature difference t that f the surrunding tissues 6

7 Size Size is an bvius adjective when it cmes t examining and dcumenting any swelling. Size is measure in tw dimensins length x breadth and dcumented in centimetres r the apprpriate S.I. unit. When measuring a swelling place the ruler r measuring tape alngside the swelling and nt ver it as this wuld incrprate the height as well. If yu cannt measure it, then estimate it by palpatin. Fr example an varian cyst. T get sme perspective n the measurement, it is nt uncmmn t equate it t a lump f fruit r anther cmmnly recgnisable bject. Transilluminatin Sme swellings may cntain serus fluid which is clear. Therefre, when examining a swelling yu may want t determine if that swelling is transilluminable. This will indicate whether the fluid in the swelling is clear r nntransilluminable e.g. bld r pus. T test fr this; Shine a (cld) bright light surce against ne side f the swelling. Rm may need t be darkened, r a blanket r tube f paper may be used. Light seen emerging frm the ther side is termed as transilluminatin. Transilluminatin cnfirms air r clear fluid within lump Dcument as; Swelling transilluminates r swelling des nt transilluminate. Mnemnics These mnemnics may help yu t remember what yu are lking fr and what yu shuld be nting n palpatin. Medical Students Sitting Exams Can Dive If Frget The Simple Things Medical Students Sing Every Christmas Day In Festive Trusers Sunding Terrific! Methicillin Sensitive Staph Epidermidis Can Definitely Infect Fingers, Tes, Scrtum & Testes Men Secretly Starting Exercise Can D It Fr Ten Secnds Tgether Pick yur favurite! Dcumenting yur findings Dcument yur findings as yu wuld any ther examinatin in the patient s ntes (see histry taking study guide). Remembering t use a black pen as well as dcumenting yur name which shuld be printed, yur signature, date & time plus yur rle. 7

8 Dcument yur examinatin findings. All 15 descriptrs may nt be relevant fr deep swellings, but it is usually pssible t nte size, psitin, shape, cnsistency, surface & mbility. A diagram may ften be used. Summary On inspectin check fr; psitin verlying skin Then; pulsatin & tenderness Remember yu can use the mnemnic f Pupils Only Play Tennis. Then palpate fr; mbility shape surface edge cnsistency depth indentatin fluctuance temperature size transilluminatin 8