Dr.

Muhammad Shahid Mehmood

EXAMINATION OF LUMP

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient standard or limited exposure

Relevant questions to be asked?

1. When the lump was first noticed?

2. What made the patient notice the lump?
3. What are the symptoms of lump?
4. Had the lump changed since it was first noticed?
5. Does the lump ever disappear?
6. Has the patient ever had any other lump?
7. What does the patient think caused the lump?

Examination consists of four parts

1. Inspection
2. Palpation
3. Percussion
4. Auscultation
1. Inspection
Inspect for
 Site,
 Size always in three dimensions: width, length and depth or thickness
 Shape hemi-spherical, pear shaped etc.
 Color over the lump
 Surface whether smooth or irregular

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 Dr. Muhammad Shahid Mehmood

 Surrounding area
 Edges clearly defined or diffuse.
 Any prominent veins
 Scar mark of previous surgery
 Ask patient to cough for cough sign
 Perform carnet sign in case of anterior abdominal wall swelling.

2. Palpation

 Always ask the patient for tenderness at the lump.

 Check and compare the temperature
 Confirm the findings noted on inspection as site, size, shape, surface,
surrounding skin.
 Check for composition of lump in terms of
 Consistency : Stony hard, Rubbery, Spongy, Soft
 Fluctuation and fluid thrill- in cystic lumps
 Trans-illumination- in cystic lumps
 Pulsatility : esp. in case of vascular swelling
 Compressibility: also in vascular swelling
 Reducibility

 Confirm the relations to surrounding structures with skin and underlying

structures in terms of fixity.
 Check the slip sign- in lipoma
 Regional lymph nodes examination
 State of local tissue/distal examination especially in limbs
 Arteries
 Neurological examination
 Bones and joints
3. Percussion and Auscultation
Auscultation esp. for bruit

Now cover the patient and say thanks.

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 Dr. Muhammad Shahid Mehmood

CASE PRESENTATION

There is (in this middle-aged lady/male patient) a non-tender lump on

back/shoulder/neck/trunk/forearms. It is 4cm in diameter, hemispherical in shape
with a lobulated smooth surface. The edges are also lobulated and slip away from
the fingers (slip sign). It is soft and fluctuant/but does not fluctuate, non-pulsatile,
non-compressible and non-reducible. The skin moves over it and it appears/ does
not appear to be fixed to deep tissues as it become less distinct / more distinct on
contraction of the underlying muscle. The overlying skin is normal and the
regional lymph nodes are not enlarged. The diagnosis is lipoma.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF INGUINAL HERNIA

Always do the following steps before proceeding towards the examination.

1. 1Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient ( Epigastrium to downwards, trousers off )

Relevant questions to be asked?

1. Occupation
2. Cough
3. Constipation
4. Smoking
5. Urinary Symptoms

Examination

Inguinal Hernia (Groin) examination is always done in standing position. It

consists of

1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Relevant examination includes abdominal and chest examination

Inspection

 Always do inspection from front includes groin, external genitalia, side and
back in standing position ask the patient to cough, inspect bilateral inguinal
regions, external genitalia and anterior abdominal wall and back.
 Note down the features of swelling/lump on inspection

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 Dr. Muhammad Shahid Mehmood

Palpation

 Warm both hands gently

 Ask for any tenderness
 Feel for temperature and compare it and also look for tenderness
 Confirm the findings on inspection of swelling/lump
 Can you get above the swelling in case of inguino-scrotal swelling

Get Above the swelling

NO YES

palpate the lump and do cough sign Check for consistency, fluctuation test,
transillumination, testes separately palpable
palpate both external genitalia
Feel for superficial inguinal, para-aortic and
Percussion and auscultaion supraclavicular lymph nodes

 Now ask the patient to lie on couch

 Ask the patient to reduce hernia himself if not then reduce yourself gently if
possible
 Perform ring occlusion test

Relevant examination

Abdominal Examination

 Superficial palpation
 Deep palpation

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 Dr. Muhammad Shahid Mehmood

 Palpate for hepato-splenomegally

 Look for ascites
 Urinary bladder

Chest examination

Auscultate the chest for any added sounds

Digital rectal examination

Now cover the patients and say thanks.

CASE PRESENTATION

In this young/middle-aged male patient there is visible lump in right /left groin
extending/not extending towards the scrotum. It is non-tender and overlying skin is
normal, pyriform/globular in shape, expansile in cough impulse, soft in
consistency. I cannot get above the lump. The lump is reducible through a point
above and lateral to the pubic tubercle in case of indirect inguinal hernia and above
and medial to pubic tubercle in case of direct inguinal hernia, positive cough sign
on palpation, both testes are separately palpable, ring occlusion test is positive at
both deep and superficial inguinal ring in case of indirect and in direct inguinal
hernia it is controlled at superficial ring only not deep. Abdominal and chest
examinations are unremarkable. So my diagnosis is right/left sided indirect
incomplete reducible inguinal hernia.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF PARAUMBLICAL HERNIA

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient standard ( Nipple to Mid-thigh )or limited exposure

Relevant questions to be asked?

1. Cough
2. Constipation
3. Pregnancy
4. Smoking
5. Urinary symptoms
6. Occupation

Examination

Paraumblical Hernia examination in case of obvious swelling is done in lying

position. It consists of

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Relevant examination includes abdominal and chest examination.

Inspection

 From right side at the level of abdomen

 From foot end
 Ask for cough impulse and also back of the patient for any hernia defect e.g.
lumbar hernia

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 Dr. Muhammad Shahid Mehmood

 Ask the patient to raise his head (Carnet sign)

 Look for features of lump on inspection

Palpation

 Warm both hands gently

 Ask the patient for any tenderness
 Feel for temperature and tenderness
 Confirm the features of lump on inspection
 Ask for cough impulse
 Look for hernia orifice
 Check reducibility

Look for hernial

Yes
defect size
Reducibilty
Look for neck
No
size

 Perform carnet sign

 Percussion and auscultation of lump

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 Dr. Muhammad Shahid Mehmood

Relevant Examination

Abdominal Examination

 Inspection
 Superficial and deep palpation
 Palpate for hepato-splenomegally
 Look for urinary bladder
 Ascites ( Fluid thrill and shifting dullness )
 Percussion
 Auscultation
 Digital rectal examination

Chest Examination

 Auscultate the chest for any added sounds

Now cover the patient and say thanks

CASE PRESENTATION

In this obese, middle-aged women there is non-tender reducible lump with an

expansile cough impulse adjacent to the umbilicus that is pushed to one side and is
stretched into characteristic crescent shape. measuring _____ size in diameter and
there is a fingertip-sized defect felt in linea alba after it is reduced, temperature
overlying skin is normal and carnet sign and cough impulse is positive. Relevant
abdomen and chest examination is unremarkable. My diagnosis is paraumblical
hernia.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF BREAST

Always do the following steps before proceeding towards the examination.

1. 1Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient ( Shirt off ) or limited exposure

Relevant questions to be asked?

1. What is problem?
2. Where is lump?
3. H/O nipple discharge

Examination consists of four parts

5. Inspection
6. Palpation
7. Percussion
8. Auscultation
1. Inspection
Do in 3 positions
i. Sitting with head end at 45o
ii. Sitting with both hands above the head
iii. Leaning forward
i) Sitting with head end at 45o

Look for size, symmetry, shape of both breasts especially the one with
pathology. Inspect first normal breast, then cover it and then do inspection of
abnormal breast. Also look for skin changes like redness, puckering, peaud’o
orange, nodularity or ulcers, previous surgery scar mark, prominent veins.
Nipple & areola → Look for nipple and areola asymmetry, retraction, destruction,
discharge, previous scar mark, radiation burn.
ii) Sitting position with both hands above head

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 Dr. Muhammad Shahid Mehmood

Inspect both breasts, under the breast, both axilla for swelling,
lymph nodes, ulcers etc.
iii) Leaning forward
In leaning forward position the diseased breast will stay with
chest.
Ask the patient to press her hands against her hips → lump will reveal when
pectoralis major muscle is taut.
2. Palpation
 Always warm both hands gently before palpation especially in
winter season
 Should be done in 45o or lying position
 Always ask the patient about tenderness and compare the
temperature of lump/swelling with normal adjacent area
 Use palmer aspects of fingers
 First palpate the normal breast then abnormal
 Always do four quadrants palpation of breast including nipple
and axillary tail
 All the features of lump like size, shape, site, surface, skin over
lump, surrounding area of skin, margins, fixity with skin,
consistency, fluctuation etc.
 Palpate for the relation with skin for fixation
 Do perform for relation with underlying muscles after tauting of
pectoralis major muscle while estimating mobility at right
angles in two directions
 Palpate the diseased axilla and normal axilla for lymph nodes
status ( anterior , posterior, central, lateral or apical lymph
nodes ) and also palpate supraclavicular lymph nodes

Always do percussion and auscultation of swelling.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION FOR METASTASIS

Abdominal examination

 Superficial palpation
 Deep palpation
 Palpate liver for mets.
 Percussion and do shifting dullness for ascites
 Auscultation

Respiratory examination

Auscultate the chest both from front and back

Spine examination

Palpate the spine for tenderness

At the end of examination cover the patient and say thanks.

CASE PRESENTATION

In this middle-aged/young lady there is non-tender ,normal temperature, size

----, mobile/fixed lump in site ----, of right/left breast which is firm,
smooth/nodular having well defined edges, not/or fixed with skin and underlying
muscles with normal or dimpling of areola, normal looking nipple with no
discharge, no clinically palpable axillary lymph nodes and spine tenderness.
Abdominal and chest examination was unremarkable and there is no evidence of
lymphoedema in the arm.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF THYROID

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient ( Dupatta off )

Relevant questions to be asked?

1. Ask about pressure symptoms ( dyspnea, dysphagia, strider)

2. Ask about palpitation
3. Heat /cold intolerance
4. About anti thyroid medication

Examination of thyroid should be done in 3 positions.

i. Front
ii. Back
iii. Front
I. EXAMINATION FROM FRONT

Inspection

 First do inspection of thyroid as swelling regarding its components like

size,shape,site,surface,surrounding skin,visible veins, scar mark etc.
 Do Pizillo method for inspection.
 Ask the patient for Pamberton’s sign especially in short neck
 Ask the patient for deglutition while offering him/her a glass of water
and observe the movement with deglutition.
 Ask the patient to protrude his/her tongue to rule out thyroglossal cyst.
 Look for thyroid status while doing inspection

Hyperthyroid Hypothyroid

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 Dr. Muhammad Shahid Mehmood

-Restlessness, tremors -Myxedema fascies

-Plethoric fascies -Periorbital puffiness

-Exophthalmos -Drowsy, thin brittle hair

-Chemosis -loss of outer third of eyebrow

Palpation

 Warm both hands gently

 Always ask about tenderness and compare temperature of swelling with
surrounding normal skin
 Palpate trachea
 Confirm the size , shape, surface, edges, consistency, pulsatility,
compressibility, reducibility
 Palpate the skin for its attachment with swelling
 Palpate the gland for its adherence to underlying structures.
 Do transillumination in case of cystic thyroid swelling and also check for
fluctuation.

Percussion & Auscultation

 Percuss for lower border in case of large swelling and also percuss
supraclavicular fossa.
 Auscultate for carotid and thyroid bruit

II. EXAMINATION FROM BACK

 Examine in flexion position of neck

 Paplation of swelling in Lahey’s method
 Assess the lower border while ask the patient to drink one /two sips of water.
 Perform Kocker’s method while noticing for strider
 Perform Berry’s sign while palpating carotid artery
 Palpate the lymph nodes
 Palpate the head for metastasis in follicular carcinoma
 Check for proximal myopathy
 Check zefneggar sign
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 Dr. Muhammad Shahid Mehmood

III. EXAMINATION FROM FRONT

Hands

Hyperthyroidism Hypothyroidism

Pulse- tachycardia, irregular Pulse may be bradycardia

Warm and sweaty palms, tremors Dry, cold and rough palms, tingling

And numbness, Tinel’s test

EYE SIGNS
 Check convergence
 Ophthalmoplegia
 Lid lag – Von-Giraffe sign – upper eyelid does not keep pace with
eyeball as it follows finger in upper and down movement.
 Lid retraction –Stillwag’s sign- upper lid raised & lower lid normal
 Jaffrey’s sign- ask the patient to look at the roof
 Check for pretibial myxedema- hypothyroidism
 Perform ankle reflex
 Auscultate the heart
 Auscultate the chest
 Palpate the Spine for tenderness

Say thanks to patient and cover the patient.

CASE PRESENTATION
Sir in this young/middle-aged patient there is nontender, normal temperature
swelling in front of neck moving on deglutition , with no relation on tongue
protrusion, size- in case of small swelling, extending from one sternomastoid to
other sternomastoid and suprasternal notch to adam’s apple, not adherent with skin
or underlying muscles, no clinically palpable lymph nodes, Berry’s sign, Kocker’s
sign are unremarkable, eye signs are unremarkable with pulse is ---/min and the
patient is clinincally euo-/hypo-/hyperthroid.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF VARICOSE VEINS

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient epigastrium downwards

Relevant questions to be asked?

1. Occupation
2. Trauma
3. H/O fever and limb swelling
4. H/O previous limb surgery

Inspection

 Both anteriorly and posteriorly in standing for dilated or torturous

subcutaneous veins
 Compare both legs
 Look for distribution of varicosities
 Look for complications of varicose veins such as oedema, hemosiderin
deposition, lipodermatosclerosis, eczema and ulceration
 Look for cough impulse for sephena varix

Palpation (on Standing)

 Warm both hands gently

 Ask for any tenderness
 Feel the temperature
 Feel the veins along their length
 Description of any complication
 Feel SF junction just medial to the femoral pulse for cough impulse for
incompetent SF junction
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 Dr. Muhammad Shahid Mehmood

 Schwartz test for fluid thrill from upside down taping the SF junction and
feel while placing the hands on medial calf just below the knee for
incompetent valves
 Single Tourniquet test for SF junction competency
 Four tourniquet tests for perforators incompetency
 Perthe’s test
 Auscultation of varicose veins at the site of venous cluster only if they don’t
decompress on supine ( bruit indicating AV fistula)

Examination of external genitalia

Examination of abdomen

DRE if indicated

Now cover the patient and say thanks.

CASE PRESENTATION

In this young/middle-aged patient there are visible, dilated/torturous veins over

medial aspect/posterolateral aspect of right/left/both legs in the distribution of
long/short sephanous veins with evidence of venous insufficiency in the gaiter area
with edema, pigmentation, lipodermatosclerosis , eczema and ulceration / or just
thickening with discoloration around ankle . There is palpable saphena varix in
right/left/both groins with a positive cough impulse and tap test (Schwartz test). On
tourniquet test large/short saphenous system is involved with incompetent SFJ/SPJ
and the perforators. Abdominal examination is unremarkable. The diagnosis is
right/left/both varicose veins with/without venous insufficiency.

Venous ulcer presentation

There is large, shallow, painful ulcer on the medial side of the gaiter area about
size ____ in diameter in a well-perfused foot with good pulses. The edges are
gently sloping or terraced and the base is red and velvety/ white and fibrous.
Yellow, sloughy anf offensive. Surrounding tissue show signs of long-standing
venous disease including edema, pigmentation (hemosiderin deposition),
lipodermatoscelorosis and varicose veins. This is a venous ulcer.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF PERPHERAL VASCULAR

SYSTEM/ISCHEMIC LIMB

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient epigastrium downwards

Relevant questions to be asked?

1. Pain on rest.
2. Pain on walking.
3. H/O trauma.
4. H/O smoking
5. Co-morbidities

Examination

Inspection (Lying Position)

 Comparison of both legs for signs of ischemic( loss of hairs, shiny skin,
color change, venous guttering ( collapsed veins which look like pale blue
gutters in subcutaneous tissue) and loss muscle bulk)
 Ulceration on pressure areas
 Ulceration in web spaces

Palpation

 Warm both hands gently.

 Ask for tenderness and compare the temperature.
 Check for Capillary refill and compare it.

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 Dr. Muhammad Shahid Mehmood

 Perform Buerger’s test for color change and pain in limb in both leg
elevation and while patient to sit up and swinging the leg over the edge of
bed—if the leg go engorged and purple test is positive.
 Venous guttering ----- on raising the leg 10-15° above the horizontal is a sign
of significant ischemia
 Check B/L pulses up to carotids
 Auscultate the vessels for bruit.
 Auscultate the heart for heart murmurs and atrial fibrillation and lungs
 Check the blood pressure in both arms.
 Assess the Ankle-brachial pressure index
 Neurological examination
 Sensory – touch and pain
 Motor- Bulk of muscle, tone, movement, power and reflexes
 Palpate regional draining lymph nodes if infection/ulceration present
 Abdominal examination for mass or aneurysm

Now cover the patient and say thanks.

CASE PRESENTATION

This middle-aged to elderly male patient has nicotine stained fingers. His leg
right/left/both is pale, shiny with loss of hair and muscle bulk on right/left side
with venous guttering, cyanosis and rubor around feet. His right/left foot is
painful at rest with or without ulcers. The right/left/both feet are cold up to calf
and Capillary refill is normal or delayed on right/left foot. Pulses are present on
right side and on left side femoral pulses are present but popliteal pulse is
diminished and foot pulses are absent. Buerger’s test is positive at 50°on right
and 20°on left. Neurological examination is normal and no lymphadenopathy.
Abdominal examination is unremarkable.

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF ISCHEMIC UPPER LIMB

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient shirt off

Relevant questions to be asked?

1. H/O pain after activity.

2. Dominant hand.
3. Problem?

Examination

Inspection

 No SOB, overweight or cyanosis.

 Look both upper limbs in supination and pronation.
 Look for Nicotine staining, clubbing and wasting of pulp of the finger, skin
changes, pallor or discoloration.
 Look for B/L supraclavicular fossa.

Palpation

 Warm both hands gently.

 Ask for tenderness
 Feel the temperature of hands
 Check Capillary refill
 Compare pulses bilaterally and B/L blood pressure
 Perform Allen’s test
 Check for peripheral Nerves ( neurological examination )
 Palpate supraclavicular fossa esp. for cervical rib.

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 Dr. Muhammad Shahid Mehmood

 Check for bruit in supraclavicular fossa

 Palpate lymph nodes

Special Tests for Cervical Rib

 EAST ( elevated Arm Stress Test )

 Modified Addison Test

Now cover the patient and say thanks

CASE PRESENTATION

In this young/middle-aged patient right hand is pale as compared to left hand with
no ulceration or blackening of fingers and wasting of muscles. Right hand is cold
as compared to left hand and capillary refill is delayed in right hand with
diminished radial and brachial pulses on right upper limb. Carotid pulses are B/L
normal, equally palpable. Distal neurological status is intact. No swelling or bruit
noted in right supraclavicular fossa. EAST and modified Addison tests are normal.

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 Dr. Muhammad Shahid Mehmood

NEUROLOGICAL EXAMINATION OF UPPER LIMB

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient shirt off

Examination

Inspection

 No obvious abnormalities to see regarding patient himself who looks healthy

or regarding his face for asymmetry ( hemiplegia, nystagmus, wasting,
ptosis, small pupil ( Hornor’s syndrome ) or neck
 Put your hands out in front of you please? To look at his back, scar mark,
tremors , muscle wasting or swollen joints

Let the patient Sit back

Examination of Arm

 Ask for Painful or stiff arm anywhere.

 Check the tone of upper limb.
 Check the power and examine Deltoid-C5, Biseps C5,C6, Triceps C7,
Gross functional test C8,T1 while squeezing fingers, Radial Nerve C7,
Finger extension, Wrist extension Radial C7, Dorsal Introssei- Ulnar,
Palmar introssei-Ulnar, Abductor pollicis brevis-Median Nerve.
 Coordination test – Dysdiadokokinesia
 Check for Reflexes – Biseps, Triceps and supinator
 Sensory system examination – Touch, Joint position and vibration sense
( propioseption)
 Check the range of movement of Neck, shoulder, elbow and wrist.
 Check the pulses

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 Dr. Muhammad Shahid Mehmood

Examination of Median Nerve

Inspection

 Look for thenar wasting, Simian Thumb ( like a monkey ), cigarette burns
or local trauma between index and middle finger, wasting of lateral aspect of
forearm and Benedictian sign ( extended index finger like that of
Benedictian Monk giving a blessing due to paralysis of flexor digitorum
profundus)
 Stretch both arms please and look for Cubitus valgus or varus for old
supracondylar fracture and scar..

Palpation

 Superficial palpation of median nerve – ask for flexion of fist against

resistance and ask for any tenderness, numbness or tingling in hand.
 Check for sensation touch in median nerve distribution
 Check the power - test for abduction of thumb (abductor pollicis brevis)
while asking the patient to touch your finger and then push against
resistance. check Opposition of thumb, check for pronator teres- hold patient
hand like a handshake and twist it against resistance while feeling forearm
 Tinnel’s sign
 Phalen’s test

Examination of Ulnar Nerve

Inspection

 Look for claw hand

 Look for ulceration of skin, wasting of hypothenar eminence ,dorsal
first web space and median forearm
 Stretch both arms please and look for Cubitus valgus or varus for old
supracondylar fracture and scar.

Palpation

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 Dr. Muhammad Shahid Mehmood

 Palpate the nerve at Elbow and wrist – ask for tenderness, numbness
or tingling
 Check the power
- Testing the introssei –card test
- Check the abduction of index and little finger
- Froment’s test for adductor pollicis

 Check the sensory system in ulnar nerve distribution

Examination of Radial Nerve

Inspection

 Look for wrist drop, forearm wasting, triceps wasting

Check for Power

 Check the power of extensors of fingers and wrist

 Supination test
 Check for brachioradialis
 Check the power of triceps
 Check the sensory system in nerve distribution

EXAMINATION OF PAROTID LUMP (GLAND)

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 Dr. Muhammad Shahid Mehmood

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient up to supraclavicular fossa

Relevant questions to be asked?

1. Pain
2. Association of size with eating
3. H/O fever

Examination

Inspection

 Swelling over the angle of right/left/both jaw or in front of tragus of ear

 Look for site, size, shape, surface, edges, surrounding skin and compare with
other side.
 Inspect the oral cavity

Palpation

 Warm both hands gently

 Ask for tenderness and compare temperature
 Confirm the findings on inspection regarding site, size, shape, surface,
edges, composition, consistency, fluctuance, pulsatility, compressibility,
reducibility, fixity, overlying and surrounding skin.
 Examine the lymph nodes- parotid, mastoid, occipital, neck.
 Examine the oral cavity- lifting the tongue, move to left or right, for any
ulcer or tonsillar swelling. Palpation with glove for any stone in parotid duct
area.
 Examine the face for facial nerve – show me your teeth, raise your eyebrows
like this, scrunch your eyes tight closed. Fill the oral cavity with air while
mouth closed.
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 Dr. Muhammad Shahid Mehmood

 Examine the scalp

 Examine the ear

Always perform percussion and also auscultate the lump as part of examination.

Now cover the patient and say thanks

CASE PRESENTATION

There is (in this middle-aged lady/male patient) a non-tender lump just anterior and
superior to angle of the jaw on right/left side. It is ----- cm in size, hemispherical in
shape with a smooth surface and distinct edges. It is hard/soft/firm and rubbery,
dull to percussion and not fluctuant, compressible, reducible or trans-illuminable.
Skin over it moves freely and it is mobile with normal overlying and surrounding
skin. The regional lymph nodes are not enlarged and facial nerve is intact.

EXAMINATION OF SUBMANDIBULAR GLAND

Always do the following steps before proceeding towards the examination.

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 Dr. Muhammad Shahid Mehmood

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient up to supraclavicular fossa

Relevant questions to be asked?

 Association with eating

Inspection

 Swelling beneath horizontal ramus of right/left/both mandible

 Look for site, size, shape, surface, edges, surrounding skin and compare with
other side.
 Look the swelling on tongue protrusion
 Inspect the oral cavity

Palpation

 Warm both hands gently

 Ask for any tenderness and compare the temperature
 Confirm the findings on inspection regarding site, size, shape, surface,
edges, composition, consistency, fluctuance, pulsatility, compressibility,
reducibility, fixity, overlying and surrounding skin.
 Examine the lymph nodes- parotid, mastoid, occipital, neck.
 Examine the oral cavity- lifting the tongue, move to left or right, for any
ulcer or tonsillar swelling. Palpation with glove for any stone, Bi-manually
palpate on both sides, press and see discharge from duct area.

Always percuss and auscultate the lump as part of examination

Cover the patient and say thanks.

CASE PRESENTATION

In this young/middle-aged patient there is non-tender lump beneath the horizontal

ramus of mandible in front of right sternomastoid, ---cm in size, flattened ovoid in
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 Dr. Muhammad Shahid Mehmood

shape and smooth with distinct margins anteriorly, posteriorly and inferiorly. It is
rubbery hard, does not fluctuate or trans- illuminate and is non-compressible, non-
reducible and non-pulsatile, dull to percussion. Overlying and surrounding skin is
normal. On examining and palpating oral cavity there is no lump or ulcer evident
from inside. Bimanual palpation shows it to lie beneath the floor of mouth; there is
no visible or palpable stone in the submandibular duct and no discharge from the
orifice of the duct. Regional lymph nodes are not enlarged.

EXAMINATION OF NECK SWELLING

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient

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 Dr. Muhammad Shahid Mehmood

3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient up to supraclavicular fossa

Relevant questions to be asked?

1. Age of patient
2. Duration
3. What problem is it causing?

Inspection

 From the front

 Compare both sides
 Look for the features of swelling
 Any scar mark, distended neck veins, thyroid
 Ask to swallow
 Ask for tongue protrusion

Palpation

 Warm both hands gently

 Ask for tenderness and compare the temperature
 Palpate the lump from front and confirm the findings on inspection
 Palpate from behind and palpate the lymph nodes
 Examine the oral cavity
 Examine the face and scalp
 Examine the ear

Relevant Examination

 Abdomen- look for liver , spleen

 Inguinal , para-aortic and axillary lymph nodes
 Chest examination – auscultation

Cover the patient and say thanks

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 Dr. Muhammad Shahid Mehmood

EXAMINATION OF ULCER

Always do the following steps before proceeding towards the examination.

1. Greetings
2. Introduce yourself and also ask the name of patient
3. Consent
4. Privacy – ask for female attendant or chaperon
5. Exposure of patient

Inspection

On inspection note;

 Size and shape of the ulcer

 Number – single or multiple
 Location of ulcer
 Margin and edge of the ulcer
- Margin is the border or transitional zone of skin around the
ulcer. Healing ulcer margin is white outer, blue central and
red inner. Inflamed margin and fibrosed margin.
- Edge is the mode of union between the floor and the margin
of ulcer. It is inspected as well as palpated. It has five types
i. Sloping edge – healing ulcer
ii. Punched edge – trophic ulcer
iii. Undermined edge – tuberculous ulcer
iv. Raised and everted edge – malignant ulcer
v. Raised edge – rodent ulcer
 Floor of the ulcer is the exposed surface of the ulcer. Note the type
of granulation tissue, slough and discharge from the floor of the
ulcer.
 Surrounding skin whether cellulitis, pigmentation and eczema in
venous ulcer, multiple scars and puckering in tuberculous ulcers,
hypopigmentation in non-healing ulcers, marjolin’s ulcer in scarred
area.

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 Dr. Muhammad Shahid Mehmood

Palpation

 Warm both hands gently

 Always ask for tenderness
 Palpate the surrounding skin
 Ulcer: Palpate ulcer edge, floor and base.
Edges in case of Healing ulcer is soft, firm in non-healing
ulcer and hard in case of malignant ulcer
 Palpate for fixity with underlying structures

Focal Examination

 Examine the regional lymph nodes

Lymph nodes will be hard, discrete and non-tender - Malignant ulcer
Soft and tender - Infective cause
Non-tender and matted - Tuberculosis
 State of the arterial and venous circulation
 Neurological examination
Sensory – touch and pain
 Movements of the surrounding joints
 For trophic ulcers :
- Map anesthetic area
- Search features of leprosy – thickened great auricular nerve,
hypo-pigmented and anesthetic patch, leonine face
- Detailed neurological examination

Systemic examination

1. Cardiovascular system for evidence of congestive cardiac failure

2. Respiratory system for evidence of tuberculosis
3. Abdominal examination for splenomegaly and hemolytic anemia
for ischemic ulcers.

Now cover the patient and say thanks.

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