MASS ULCER

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MASS ULCER DSF

• Dr.AbdulWAHID M Salih
• M.D. Surgery

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The history OF A LUMP

• Duration
• How discovered
• Symptoms ? pain
• Changes ? ?in size
• Other lumps
• Any cause ? Trauma

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Examination of a Mass

• Exterior
• Site
• Skin
• Size
• Shape
• Surface
• Temperature
• Tenderness
• Edge
• Mobility and attachment

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• Interior
• Get above or below it.
• Intra or extra abdominal.
• Consistency
• Pulsatility
• Cough impulse
• Reducibility
• Compressiblity
• Expressiblity
• Fluctuation
• Percussion
• Indentation
• Slippering
• Transillumination
• Auscultation

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• Surrounding
• Neurovascular
• Nodes Lymph nodes
• Indurations
• Invasion
• Two sites
• Yet

N I T Y
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Site Single vs. Multiple. Distance from a
bony prominence landmark.
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• Skin
• Colour and texture of overlying skin (erythema)
• scars, inflammation, bulge, visible pulsation,

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Size three dimensions Shape irregular,
spherical, (reasonable to use descriptive terms
e.g. pear shaped) Surface Smooth vs. rough vs.
indurated.
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• Temperature Feel with back of fingers on
  surface surrounds.
• Compare with identical site.
• TendernessAsk the pat.when feel pain.See the
  face of the pat as you palpate
• .

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• EdgeClear vs. poorly defined.
• (clearly defined or indistinct)
• Regular or irregular
• 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.

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Interior Get above or below it Intra or
extra abdominal
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ConsistencySoft Spongy Rubbery Firm. Hard Stony
hard
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• Pulsatile
• Assess with 2 fingers on mass
• Transmitted pulsation
• both fingers pushed same direction
• 2.Expansile pulsation
• fingers diverge (esp for AAA).

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Cough impulse Ask the pat. To cough
(hernia) Irreducible Mass Decreases or
disappear with pressure Mass reappears only on
cough, etc
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Compressible Mass decreases or disappear with
pressure but reappears immediately upon
release. Expressible Discharge when pressing
the mass
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• Fluctuation
• fluid-containing
• 2 fingers in "peace sign" on either edge of lump,
  
• tapping lump center with index finger
• fluctuant lump will displace peace sign
  fingers.Very large masses by a fluid thrill.
• Percussion Dullness. Resonance

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• Indentation
• Press the centre
• Either containing pus or faeces
• Slippering
• Press the edge
• lipoma

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• Transillumination
• If applicable.A torch behind lump
• light to shine through.Example testicular
  mass.
• Contain water, serum, lymph or plasma
• Auscultation
• Bruit
• AV fistula-systolic murmur
• Hernias-audible bowel sounds

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• Surrounding
• Neurovascular
• Art. ,veins and nerves distal to the mass
• Lymph nodes
• Regional lymph nodes

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• Indurations surrounding skin
• Malignancy and abscess
• Invasion
• surrounding structures
• Two sides
• Yet
• Associated mass
• The cause or effect of the mass
• General examination (the whole pat).

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ulcer A Break in epithelial surface,
extending to all layers of epithelium.
Typical venous ulcer at the internal malleolus
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• Aetiology
• 1-Trauma
• inadequately treated traumatic ulcer is the
  commonest.
• 2-Infection
• Acute tropical ulcer,
• Chronic infection tuberculosis, syphilis
• 3-Vascular
• venous very common
• deep or superficial insufficiency
• arterial large or small vessel dz (diabetic)

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Aetiology 4-Haemoglobinopathy
in HbSS and HbSC. 5-Neurotropic (tropic)
leprosy, diabetic cord lesions,
peripheral neuropathy. 6-Pressure
sore 7-Neoplastic 1º or 2º
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• History
• When arose.
• Change in size, appearance, etc.
• Whether previous ulcers.
• Painful vs. painless.
• PMH varicose veins, DM, DVT,
• trauma, intermittent claudication,
• vascular dz, infections, CA.
• SH smoking, occupation invloving
• standing up for long periods.

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Examination of an Ulcer

• Generally examination of an ulcer will follow the
  same pattern as examination of an lump (e.g.
  site, size, shape etc)
• However, there are additional features you should
  examine for
• Base
• Floor
• Edge
• Depth
• Discharge

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• Floor
• which is seen
• Color
• Slough
• Granulation tissue (capillaries, collagen,
  fibroblasts, inflammatory cells)
• Deeper structures such as tendon or bone may also
  be visible

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• Base
• which is felt
• Soft
• Firm
• Hard

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• Edge
• Sloping
• (healing ulcer)
• 2-Punched out
• (diabetic neuropathy,
• arterial ischaemia
• syphilis)

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Edge 3-Undermined
(tuberculosis, pressure necrosis) 4-Rolled
(basal cell carcinoma) 5-Everted
(squamous cell carcinoma)
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Depth Recorded by
anatomically Describing the structures it has
penetrated
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• Discharge
• serous,
• purulent.
• bloody
• Always take a swab

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• Surrounding
• Neurovascular
• Nodes Lymph nodes
• Indurations
• Invasion
• Two sites
• Yet

N I T Y
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• Surrounding
• Neurovascular
• Art.,veins and nerves proximal to the ulcer
• Important in lower limb ulcers
• Lymph nodes
• Regional lymph nodes
• Enlarged (infection, malignancy)

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Diabetic foot ulcer A-Neuropathy
(more sensation is lost) B-Peripheral vascular
disease (less circulationto bring enough
oxygen to repair tissue damage) C- shape of the
foot Coexisting abnormalities increases local
pressure and callus)
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• A-Diabetic Neuropathy
• by testing if the pat. can feel
• 1-Pain of a pin prick
• 2-Touch of a cotton wool
• 3- propioception
• 4-Vibration of a tuning fork.

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Testing vibration sensation 5- biothesiometer.

• A probe is applied to part of the foot,
• usually on the big toe
• As soon as can feel
• the vibration and the reading.
• Reading from 0 to 50 volts
• The risk of developing a
• neuropathic ulcer is much
• higher if a person has a
• biothesiometer reading
• greater than 30-40 volts

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Testing touch pressure sensation
6-monofilament A standardized filament is
pressed against the foot. When the filament
bends, its tip is exerting a pressure of 10
grams. patient cannot feel the monofilament,
he/she has lost enough sensation to be at risk
of developing a neuropathic ulcer.
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• B-peripheral vascular disease
• Claudication
• Rest pain
• The temperature of the foot
• Purplish coloured feet
• Palpat the
• Dorsalis pedis artery
• Posterior tibial pulse

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6-Ankle Brachial Index Ankle (pressure) /
Brachial (pressure)

Normal 0.9 - 1.2 Risk of vascular foot ulcer is small
Definite vascular disease 0.6 - 0.9 Risk of vascular ulcer moderate
Severe vascular disease Less than 0.6 Risk of vascular foot ulcer very high
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C-Foot Shape Abnormality

• Clawed toes
• imbalance of the muscles
• increases pressure at
• the apex of the toes
• Rocker bottom
• due to Charcot's joint
• Abnormal toe nails
• Toe nails can become infected, thickened and
  deformed

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Poor diabetic control

• Increases infection and
• impairs wound healing.
• Hba1c greater than 10.
• Maceration between the toes
• which can lead to infection
• Very dry skin with cracks
• predisposing to infection

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Poor diabetic control

• Amputation of digits
• Shiny hairless leg
• Infections (e.g. paronychia)
• Pressure sites

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• To complete examination
• Dipstick urine
• Evidence of diab. nephropathy
• Evidence of diab. retinopathy