History &

General
examination
Notes on Hx, ulcers, lumps

Qasem Al-Shaer

Notes on

History Taking

Always give the patient

your whole attention..
Treat patients as the
rational, intelligent,
human beings they are.

..and never take short

cuts!

Questions
Open
Closed
Leading Q.

You shall not use

leading questions, all
questions should leave
the patient with a free
choice of answers

Dont write and talk to

the patient at the same
time

Never start with a

diagnosis in mind..
Always start with a
SYMPTOM.

Its better not to know

the diagnosis made by
the patient or other
doctors; because none
may be correct.

 its essential to know

them BY HEART!

Your understanding and ability to solve

the practical problems of clinical
examination can only be clarified by
frequent bedside practice.

- examine as many patients as you

can.
- Nothing can be learnt without
frequent practice.
- Repetition is the secret of
learning

The ART of history

taking & clinical
examination.

~ Confidentiality

Examination of a

LUMP

What is a lump?
A compact mass of a substance?
Swelling?

Basic approach to a
lump?
1. History
2. Examination
Inspection
Palpation
Percussion
auscultation

History of a lump
When was the lump first noticed?
Doesnt mean it appeared then
What drew your attention to it?
Felt it, saw it
Pain (usually inflammatory)
Someone else noticed it
What are the symptoms?

History of a lump
How has it changed since it first appeared?
Size, shape, fluctuates?
tenderness?
Does it ever disappear?
Any others before?
What do you think the cause is?

Examination of a lump
Inspection
Palpation
Percussion
Auscultation

Examination of a lump
Site

(anatomical terms, distance from land marks)

Number
Multiple: NF, lipomatosis

Shape
Regular
Irregular

Size (3D)

Examination of a lump
Skin (color & texture)
Surface
Color: red inflamed, purple, black necrotic,
Smooth
Black punctum Sebaceous cyst
Peau d orange
Cauliflower surface (SCC)

Examination of a lump
Pulsation

Depending on the site:

Cough impulse: Abd, thorax, pelvic
Pressure effects (LL)
Movement with swallowing (thyroid)

Examination of a lump:
palpation
Temp
Over lump, and compare with surroundings
Warm well vascularised (sarcoma), also in.?

Tenderness inflammation, nerve

Surface
Smooth cystic
Lobular with bumps lipoma
Nodular goiter
Irregular Ca

Examination of a lump:
palpation
Edge, wit tips
Well defined, regular benign
Well defined, irregular malignant
Ill defined inflammatory
Slipping edge lipoma
confirm size

Examination of a lump
Consistency
Soft lipoma
FIRM
HARD, stony hard, bony, calcified

Examination of a lump
Consistency
Variable malignant

Soft
Ear lobule
Ala of nose
Firm
Uncontracted muscle
Tip of nose
Hard
Contracted muscle
Ridge of nose

Examination of a lump
CYSTIC lump
Lock for moulding: indentation Sebaceous ,
dermoid,
Fluctuation
Thrill

Examination of a lump
If the lump is cystic, then do:
Fluctuation
If large mass in 2 planes, carful!! Tissue

fluctuation!!
if small fix it between 2 fingers, press with the
third

If it fluctuates then do
Trans-illumination
clear fluid

Fluid thrill

Examination of a lump
Cough impulse:
becomes tense
Increase in size
Reducibility:
compress the lump uniformly
E.g. hernia
displacement

Compressibility
vascular hemangioma
compresses,, then expanses back rapidly

Pulsetile (expansile, transmitted)

Examination of a lump
Moves with respiration

To which tissue is the lump fixed?

Skin
Cant pinch the skin above it
Tethering? Indirectly attached

Bone
Totally immobile
Moves with the bone

Tendon: moves with it on active, fixed on

contraction against resistance, mobile on right

angle not parallel

To which tissue is the lump fixed?

Tell the patient to contract the muscle
subQ
More Prominent,
remain mobile

Muscle
Fixed, immobile
Mobile at right angle to fibers on relaxing the

muscle

Below muscle
less prominent, difficult to palpate

Palpation
Temp
Tenderness
Surface
Smooth cystic
Lobular with bumps lipoma
Nodular goiter
Irregular Ca
Edge, wit tips
Well defined, regular benign
Well defined, irregular malignant
Ill defined inflammatory
Slipping edge lipoma
confirm size
Consistancy
Soft lipoma
CYSTIC
Lock for moulding: indentation Sebaceous , dermoid,
Fluctuation
Thrill

FIRM
HARD, stony hard, bony, calcified

If the lump is cystic, then do:

Fluctuation
If large mass in 2 planes, carful!! Tissue fluctuation!!
if small fix it between 2 fingers, press with the third

If it fluctuates then do
Trans-illumination
clear fluid
Fluid thrill

percussion
Small no need?
Tympanic gas
Hydatid thrill (3 fingers)

Auscultation
Highly vascularized (thyroid goiter, sarcomas)
Aneurysm

Regional Examination
Lymph nodes
Neighboring structures
joints

Systemic

To study the disease

without books is to
sail an uncharted
sea,
While to study books
without patients is
not to go to sea at
all!!
Sir William Osler
1849-1919

Examination of an

ULCER

What is it Ulcer?
Discontinuity of any epithelial membrane
Can be on:
Skin
Mucosal GI

It is a defect with loss of epidermis and at

least part of the dermis

Basic approach to an
ulcer?
1.
2.
3.
4.

History
Ulcer examination
Focal examination
Systemic examination

History of an ulcer
When was the ulcer first noticed
Doesnt mean it appeared then
What drew your attention to it?
Pain
Bleeding
Discharge
Smell!!
What are the symptoms?
Interferes with daily activity?

History of an ulcer
How has it changed since it first appeared?
Size, shape, discharge?
Healed and broken?
Any others before?
What do you think the cause is?

Examination of an ulcer
Inspection
Palpation

Examination of an ulcer
Inspection:
Site
Size
Shape
Surface (floor)
Edge & Depth
Margin
Surroundings

Examination of an ulcer
1. Site:
in anatomical terms, in relation to nearby structures, land
marks

Venous Medial malleolus

Arterial dorsum of foot
Trophic, neuropathic weight bearing areas
Rodent face, nose
(above

a line joining angle of mouth to lobule of the ear )

Tuberculous neck, axilla, groin

Malignant lips, tongue, breast

DM

Examination of an ulcer
2. Size:
Measure, dont guess!
3D

Examination of an ulcer
3. Shape:
You can draw it

Examination of an ulcer
4. Surface:
Granulation tissue
Fibroblast
Vessels
CT
Inflammatory cells

Slough: Necrotic tissue, not yet separated

Discharge:
Type: serous, bloody, purulent
Amount: inspect the dressing

Any underlying tissue:

muscles, bone??

Examination of an ulcer
4. Surface:
Healing ulcer
Pink healthy granulation tissue,
Minimal serous discharge
Some bleeding on touch
No slough

Examination of an ulcer
4. Surface:
Ischemic Ulcer
Poor granulation
Tuberculous
Bluish unhealthy

Skin death, full thickness

Solid, brown or grey

Examination of an ulcer
4. Surface:
Scab

Examination of an ulcer
5. Edge & Depth:
Edge: the union between the floor and the margin

Sloping
Punched-out
Undermined
Rolled
Everted

Examination of an ulcer
5. Edge & Depth:
Healing ulcer
Venous ulcer can have it

Examination of an ulcer
5. Edge & Depth:

Trophic ulcer
Neuropathy DM
Arterial ischemia

Examination of an ulcer
5. Edge & Depth:
Pressure necrosis
subQ fat is more susceptible to pressure than
the skin

Examination of an ulcer
5. Edge & Depth:
BCC
Rodent ulcer
Slow growth
Site?

Examination of an ulcer
5. Edge & Depth:

SCC
Rapid growth

Examination of an ulcer
6. Margin:
transitional zone, the area between the ulcer and the normal
tissue

Healing
Red Blue White

Inflamed
Red, irregular

Fibrosed
Thick White, firm, no blue growing epithelium
Chronic, not healing

Margin: the junction btwn normal epithelium

& the ulcer (boundary of the ulcer, transitional

zone)
Edge: the area btwn the margin and floor of
the ulcer
Base: on which the ulcer rests
Floor: is the exposed surface within the ulcer

Examination of an ulcer
7. Surroundings :
infected shiny, red, edematous
varicose heperpigmintation,
Tuberculous multiple

Examination of an ulcer
Palpation
Surroundings
Temp
Tenderness

Relation to deeper structure:

e.g.Malignant ulcers will obviously be fixed to
deeper structure by infiltration

Examination of an ulcer
Palpation
Ulcer
Edge

soft: healing
Firm: non-healing
Hard: malignant

Floor, granulation
Base

If small, between 2 fingers

If large, from the floor

Examination of an ulcer
Lymph Nodes
Malignancy
Hard, discrete, non tender

Infected
Soft, tender

Examination of an ulcer
Region and Systemic
According to the type
Color, hair, pulses, temp,

Clinical features of Martorell ulcer

Martorell ulcers most commonly occur on the outer aspect of back of the lower

leg often just above the ankle. Over the Achilles tendon is another common site.
A significant proportion of patients report the ulcer began after skin trauma, but
more commonly it starts as a painful red blister or patch which turns blue then
ulcerates.
Ulcer characteristics may include:
Extreme pain out of proportion to the size and appearance of the ulcer it is
typically described as strong to excruciating
Solitary or symmetrical, affecting the same site on both lower legs
Red-purple inflamed ulcer edge
Episodes of sudden enlargement due to another area of skin death
Irregular shape
Satellite ulcers
Deep, exposing underlying tendons
Failure to respond to usual treatments for leg ulcers.

Clinical features of Martorell ulcer

Martorell ulcers most commonly occur on the outer aspect of back of the lower

leg often just above the ankle. Over the Achilles tendon is another common site.
A significant proportion of patients report the ulcer began after skin trauma, but
more commonly it starts as a painful red blister or patch which turns blue then
ulcerates.
Ulcer characteristics may include:
Extreme pain out of proportion to the size and appearance of the ulcer it is
typically described as strong to excruciating
Solitary or symmetrical, affecting the same site on both lower legs
Red-purple inflamed ulcer edge
Episodes of sudden enlargement due to another area of skin death
Irregular shape
Satellite ulcers
Deep, exposing underlying tendons
Failure to respond to usual treatments for leg ulcers.

Marjolin Ulcer
After longstanding, non-healing ulcer
They transform into malignant ulcer (SCC)
The previous image

THANK YOU