PHYSICAL EXAMINATION General examination Patient is lying comfortably in supine position supported with one pillow.

He is alert and conscious. He is not in pain or respiratory distress. There is intravenous branula inserted at his right dorsum of hand without running infusion. Vital signs Temperature: 37.00C Blood pressure: 126/84 mmHg Pulse rate: 76 beats/min, regular rhythm, normal volume Respiratory rate: 18 breaths/min Hand: Both palms are warm and dry. No pallor on palmar crease. No palmar erythema. No koilonychia. No peripheral cyanosis. Capillary refill time is less than 2 seconds.

Abdominal examination a. Inspection: The abdomen is not distended, symmetrical in shape and move with respiration. The umbilicus is centrally located and inverted. There is no scar, no dilated vein, no visible pulsation and peristalsis noted. The hernia orifices were intact. b. Palpation: On light palpation, the abdomen is soft and nontender. On deep palpation, no mass palpable, the liver and spleen were not palpable. Both kidneys were not ballotable. c. Percussion: No shifting dullness. d. Auscultation: Normal bowel sound present.

Head and Face There is no conjunctival pallor and no jaundice on sclera. The mouth is moist, there is no central cyanosis and oral hygiene is good. No angular stomatitis. His throat is not injected and tonsil not enlarged. No discharge from nose and ears. Neck No gross enlargement of thyroid noted and jugular venous pressure not elevated. No palpable lymph nodes noted.

Lower limbs: No ankle oedema.

EXAMINING A MASS Inspection 1. Site Also, single vs. multiple. Distance from a bony prominence landmark. Size Shape Surrounds Remote surrounds first, then local surrounds. Also, surrounding neurological or motor deficits. Surface Smooth vs. rough vs. indurated. Skin, scars. Edge Clear vs. poorly defined. Transillumination, if applicable. Whether a torch behind lump will allow light to shine through. Esp. used in testicular mass.

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Fluctuation [fluid-containing] Assess by placing 2 fingers in "peace sign" on either edge of lump, then tapping lump center with index finger of other hand: fluctuant lump will displace peace sign fingers. Very large masses can be assessed by a fluid thrill. Irreducible Compressible: mass decreases with pressure, but reappears immediately upon release. Reducible: mass reappears only on cough, etc.

Percussion and auscultation

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Percussion: Dullness. Resonance. Auscultation: Bruit.

General patient 1. Regional lymph nodes around mass. 2. Overall appearance of the patient. Mnemonic 4 Students and 3 Teachers around the CAMPFIRE: Site Size Shape Surface Tenderness Temperature Transillumination Consistency Appearance of patient Mobility Pulsation Fluctuation Irreducibility Regional lymph nodes Edge

Palpation 1. Temperature Feel with back of fingers on surface, surrounds. Tenderness Ask to tell when feel pain. Nerve: can cause pins and needles. Consistency Soft, spongy, firm. Mobility and attachment Move lump in two directions, right-angled to each other. Then repeat exam when muscle contracted: Bone: immobile. Muscle: contraction reduces lump mobility. Subcutaneous: skin can move over lump. Skin: moves with skin. Pulsatile Assess with 2 fingers on mass: Transmitted pulsation: both fingers pushed same direction. Expansile: fingers diverge (esp for AAA).

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