Breast

Examination
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 Breast Examination • Skin changes on breast
➔ Redness
Positioning : sitting position ➔ Peau d’ orange
➔ Cannot examine in lying position because the ➔ Dimpling : Intramammary tumor pulls on
ligament of cooper (accentuated by raising
pendulous breasts sag laterally hands above head)
➔ Ulcer
Exposure : base of the neck ➔ umbilicus
➔ To able to see supraclavicular node Ask patient to press on her hip; contract the
pectoralis muscle
Inspection • Repeat the inspection
Patient sit upright, put hands at side; relax the • Scar? ➔ ask the patient to raise both UL, inspect
pectoralis muscle the scar
• Nipple • See any swelling on the breast
➔ Symmetry : show to see the symmetry
While pressing the hip, ask patient to lean forward
➔ Inversion
• To see either the nipple symmetry or not
➔ Discharge, retraction, excoriation, scar • Asymmetry ➔ fix to the skin
• Areolar normal or not? : Eczema • Upper limb edematous?
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 Breast Examination
Palpation (gloves if ulcerative); lying 45° • Press the nipple horizontal & vertical ➔ look for
• Palpate the normal breast first then pathological any discharge
breast : divide into 4 quadrants • Test for fixation
➔ Upper inner ➔ lower inner ➔ lower outer ➔ ➔ Ask patient to press on her hips or put the
upper outer ➔ axillary tail hands behind the head
• Use one hand to support the breast when
palpating • Axillary lymph node
• Feel for temperature first ➔ Apical ➔ central ➔ anterior ➔ posterior ➔
lateral
• Describe the lump
➔ Location
➔ Solitary or multiple
➔ Shape, size
➔ Surface, consistency (firm or hard)
➔ Margin (regular or irregular)
• Supraclavicular and infraclavicular node palpate
➔ Test for fluctuation from behind and other LN
➔ Tenderness, fixity to skin by pinching the skin
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 Breast Examination
Complete with (check for metastasis)
• Lungs: Auscultate and percuss lungs for pleural
effusion
• Abdomen: Lie patient down to palpate abdomen
for hepatomegaly
• Bone: From behind, palpate along vertebral
spines and ribs for bony tenderness

Differential diagnosis of a breast lump

i. Breast ca
ii. Fibroadenoma
iii. Breast cyst
iv. Breast abscess
v. Phyllodes tumor if huge
vi. Traumatic fat necrosis (rare)
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 Thyroid
Examination
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 Thyroid Examination
Position : sitting position • Comment on
i. Site (lateral, central)
Exposure : from top of head to mid chest (take off
the shirt) ii. Estimated size, shape
iii. Skin changes ➔ skin redness or ulcer
Prepare a cup of water
iv. Dilated vein or visible pulsation
Inspection v. Scar?
• Inspect from front then lateral view vi. Ascends upon swallowing or tongue
protrusion?
• Swallowing test
➔ Take a sip of water in the mouth
➔ Only swallow when instructed
• Tongue protrusion test
➔ To test for thyroglossal cyst
➔ Open the mouth first, ask pt to protrude
tongue
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 Thyroid Examination
Palpation (from behind) • Check tracheal deviation
• Temperature, tenderness
Percussion
• Palpate by pushing to a side
• For retrosternal extension
➔ Location, size, shape, surface, consistency,
margin
Auscultation
➔ Pinch to see attachment to overlying skin
• Over carotid for carotid bruit
➔ Ask the patient to look to one side ➔ test for
fixity (fixed or mobile) ➔ Due to external compression or blockage of
tumour invasion
• Carotid pulse
• Over upper pole or directly anterior to the toxic
➔ Turn head to one side and check the opposite
gland for thyroid bruit ➔ hyperthyroidism
carotid pulse
➔ Due to increase vascularity
➔ Berry’s sign positive if unable to palpate
carotid pulse
• Lymph node enlargement
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 Thyroid Examination
Check thyroid status (Hyperthyroid) • Pulse : feel for 1 minute
• See general condition ➔ Resting tachycardia: primary thyrotoxicosis
➔ Restless ➔ Atrial fibrillation: sec. thyrotoxicosis
➔ Depressed • Proximal myopathy
• Talk to patient to see hoarseness, low pitch voice • Eye
➔ Hoarseness: Recurrent laryngeal nerve ➔ Exophthalmos: Look lateral then from behind
involved ➔ Cannot see the lower limbus of sclera
➔ Low pitch voice/unable to shout: external ➔ Diplopia: ask see how many fingers
laryngeal nerve
➔ Lid retraction
• Hand
➔ Lid lag: finger in horizontal moves up then
➔ Warm, sweaty goes down
➔ Thyroid acropachy, palmar erythema ➔ Chemosis, proptosis
➔ Tremors: fine tremors on outstretched hand
➔ Visual field: H direction
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 Thyroid Examination
• Reflex Differential diagnosis
➔ Hyperreflexia Diffuse
• Pretibial myxedema • Physiological ➔ Puberty, Pregnancy
• Pathological ➔ Graves disease, Hashimoto
At the end of my examination, I would like to thyroiditis
complete by checking the evidence of metastasis:
Nodular
• Lungs: Auscultate lungs for reduced air entry or
• Solitary
bronchial breath sound
➔ Colloid cyst or goiter
• Abdomen: Lie patient down to palpate abdomen
for hepatomegaly ➔ Dominant nodule of a multinodular goiter
• Bone: From behind, palpate along vertebral ➔ Thyroid adenoma
spines and ribs for bony tenderness ➔ Thyroid carcinoma
• Multiple
➔ Toxic: Toxic MNG
➔ Non-toxic: Non-toxic MNG
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 Hernia
Examination
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 Hernia Examination
Before examination, I would like to close the • Location : Swelling at the left inguinal area
curtain for patient’s modesty extending down into the left hemiscrotum/to the
deep ring but not into the hemiscrotum
Exposure : I would like to expose from the nipple • Shape
line to the mid-thigh, but for patient’s modesty, I
would like to only expose from umbilicus to mid • Unilateral/bilateral
thigh • Skin changes
➔ Skin redness
Position : standing position
➔ Shinny skin
➔ To determine the extend of hernia
➔ Visible pulsation or ulcer
Inspection • Bag of worm appearance
• Inspect also the groin and scrotum on the
• Scar?
opposite side
➔ No similar swelling appeared on the • Ask patient to cough to see bulging ➔ for cough
contralateral site impulse

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 Hernia Examination
Ask patient to stand if it is a small hernia. Why? Palpation (wear gloves!!)
• To see how much is the extend of the hernia into • Tenderness
the scrotum
• Temperature
• Inspect the contralateral hernia
• Some scrotal swelling is invisible during supine, • Consistency ➔ cystic, solid or firm
e.g: varicocele • Can get above the swelling?
• Feel the separation of the hernia and the testis
*p/s: No need stand if the hernia is too big
➔ Show the neck of scrotum is full with swelling
content
Ask the patient to lie down
➔ Palpate the testis bilaterally and comment
• Check if the swelling reduce spontaneously whether palpable bilaterally and separable?
➔ If not, ask the patient to reduce it (manually)
• Spermatic cord ➔ palpable or not
• If the swelling cannot be reduced at all, either:
➔ Irreducible hernia
➔ Lipoma or sarcoma
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 Hernia Examination
Percussion (usually not done)
• To differentiate the content
➔ Resonance : enterocele
➔ Dull : omentocele
• I would like to skip percussion because might
cause discomfort to patient and the content can
be differentiate using auscultation
Auscultation : patient still in standing position
• To differentiate the content
➔ Bowel sound is heard in enterocele
Special tests
1. Deep ring occlusion test ➔ in supine position
• Ask patient to reduce the hernia himself
• Locate deep ring
➔ Place the thumb 1.25 cm above the
midpoint of inguinal ligament = deep ring
➔ Occlude the deep ring with thumb or 2
fingers
• Ask patient to cough
➔ Bulge out = direct hernia
➔ Do not bulge out = indirect hernia
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 Hernia Examination
Complete examination with
• Lung examination to look for signs of COPD
• Abdominal examination to look for factors that
cause increased in intraabdominal pressure
➔ Hepatomegaly, splenomegaly, APKD, bladder
distension, ascites
• DRE ➔ to look for prostate enlargement (BPH)

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 Hernia Examination
Differential diagnosis Scrotal swelling
Inguinal swelling i. Spermatocele (Epididymal cyst)
i. Incomplete inguinal hernia ii. Hematocele
ii. Bubonocele iii. Encysted vaginal hydrocele
iii. Encysted hydrocele iv. Epididymo-orchitis
iv. Undescended testis v. Testicular abscess
vi. Testicular tumor
Inguino-scrotal swelling
i. Complete indirect inguinal hernia
ii. Varicocele
iii. Communicating hydrocele
iv. Lipoma in the cord

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 Stoma
Examination
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 Stoma Examination
Positioning : supine position • Size : in diameter, height from skin
• Number of lumen & shape
Exposure : whole abdomen
➔ Round & end (single lumen)
➔ Chaperone if patient opposite sex & close
curtains ➔ Oval & double barrel/loop (double lumen)
(confirm w/o bag)
Specific stoma examination • Mucosal of stoma
Inspection ➔ Spout (protrude) or flush (flat/same level with
• Associated abdominal surgical scar skin)
➔ Site, length, condition, hernia ➔ Healthy (pink) or unhealthy (dark, necrotic,
• Site (quadrant) edematous)
➔ Left or right iliac, right hypochondriac • Content
• Types of stoma bag ➔ Fluid, semisolid, solid faeces, flatus, blood,
➔ Single/two piece system pus, urine, bile
➔ Drainable/closed end
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 Stoma Ileostomy Colostomy
Stoma Examination Site Right iliac fossa Left iliac fossa
Calibre Small Large
• Surrounding skin
Mucosal Spout ~3cm ➔ Flushed/flat to
➔ Excoriation esp. in ileostomy prevent the skin
➔ Necrotic patch/gangrene irritation
➔ Dermatitis/hyperaemia Content Fluid/watery Solid/faecal
• Cough impulse ➔ Herniation/prolapse
Local Systemic
• Skin irritation • Stoma diarrhea
Palpation • Prolapse ➔ HypoNa,
• With sterile gloves; open the stoma bag, re- • Retraction HypoMg,
examine the number or shape lumen, • Ischemia HypoK
surrounding skin & content • Stenosis • Dehydration
• Ask patient to cough ➔ herniation • Parastomal • Nutritional
hernia disorder
• Bleeding • Psychological
Complete examination : Per-rectal examination • Fistulation problem
• Infection • Stones
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Varicose Vein
Examination
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 Varicose Vein Examination
Positioning : supine first
Exposure : whole lower limb until umbilicus (cawat)
Inspection
• Site, size, extend
➔ From inspection in supine position, I can see
dilated tortuous vein on the medial surface of
the lower limb extending from the medial
malleolus to the upper thigh
➔ No similar dilated vein on the lateral part
➔ Complicated by ulcer at medial malleolus
• Surrounding skin and other signs of chronic venous
insufficiency
➔ Hyperpigmented lesion on the lower half of the
leg
➔ No swelling, sinus, scar or skin redness
Ask patient to stand and inspect again to make the
vein more prominent (veins collapse on supine)
• On my inspection in standing position, the dilated
vein becomes more prominent on standing from the
medial malleolus extending up to the upper part of
the thigh
• No similar dilated veins on the lateral and posterior
aspects of legs
• Ulcer, hyperpigmented lesion in standing position
(still in standing position)
Ask patient to cough
➔ For cough impulse and thrill in the groin ➔
Saphena varix
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 Varicose Vein Examination
Palpation (still in standing position)
• Temperature
• Hardening of the varicosities
• Palpate along the varicosity
➔ On palpation, there is no tenderness on the
dilated vein ➔ superficial thrombophlebitis
➔ Press the calf for tenderness ➔ indicate DVT
• Pitting edema & pulses : femoral, popliteal, PTA, DPA
Percussion : Tap test
• Place a finger at SFJ & tap the vein that we assess
• Presence of thrill suggests continuity of vein 2° to
incompetent valve
Auscultation
• Auscultate using bell of stethoscope, presence of
bruit
➔ underlying arteriovenous malformation
Special tests
1. Tourniquet test: in supine position
• Locate the saphenofemoral junction
• Lift the patient’s leg onto shoulder & empty the
superficial vein by milking the leg toward the groin
• Apply tourniquet/finger at SFJ
• Ask patient to stand & observe the filling of the vein
➔ If the veins above tourniquet rapidly fill ➔
saphenofemoral junction insufficiency
➔ If the veins below tourniquet fill immediately ➔
perforator insufficiency
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 Varicose Vein Examination
Perthe’s test: in standing position Other examination:
• To distinguish between venous insufficiency in deep, • Abdomen: Palpation to exclude mass
perforator and superficial venous system
• Rectal or vaginal examination: To exclude a pelvic
➔ Apply tourniquet at proximal midthigh mass
➔ Ask patient to walk for 5 mins • Testes: Metastasis of testicular tumour to abdominal
LN can cause IVC obstruction
➔ Note any calf pain or venous engorgement
➔ Vein become less distended: no deep venous
insufficiency
➔ Vein remain same or more distended & calf
pain: problem with deep vein system

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Lump & Bump
Examination
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 Lump & Bump Examination
Introduction : WIPERS • Attachment ➔ relation to skin
• Edge or margin
Inspection & palpation
• Consistency
• Site
• Mobility / fixation
• Size
• Pulsation
• Shape
• Test for fluctuation
• Skin
• Irreducibility/reducibility
• Surface
• Compressibility or not
• Scar
• Regional lymph node
• Temperature
• Tenderness Thanks the patient
• Transillumination test

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