Short Case : Swelling over Right Hand

Instruction : Examine patient's hand.

This patient, a 10 years old boy has swelling/lump at his radial side of right wrist

1) Introduce urself.

2) Ask consent from parents and patient himself

3) Put patient's hand on pillow. Make sure patient is comfortable.

4) Dr cakap tadi supposely kena expose other part so.. kena bukak baju patient sbb nak cek swelling kat other part as well. But, u can ask parents/patient himself.

5) General inspection. Comment on branula attachment/alert/well nourish

6) Now focus on hand, check for muscle wasting, scar, any skin changes, deformity, swelling, pallor. (Cek both dorsally + palmarly)

7) Now, focus on the swelling

- Inspection : Site, shape, skin changes, sinus, prominent vessel, scar, deformity of fingers.

- Palpation :

- Size (eg : 5cmX3cmX1cm)measure dari lowest margin to the other side lowest margin

- temperature

- surface (smooth/irregular)

- consistency ( soft/firm/hard)

- margin (well defined/ ill defined) cek sume side.. xsume side well defined.. can be different.

- tenderness

- check for mobility of the swelling - horizontally, vertically (fixed/mobile)

- transillumination (cystic/solid) *tunnel die depend on size of swelling tuh.

8) Check for Attachment of Swelling

- if u can pinch skin = swelling not attached to skin

- if fixed mobility = swelling is attached to bone

- for muscle, we give resistance as patient dorsiflex his wrist. ask patient to lawan. (ala, macam nk assess power dalam CNS examination.. :) )

- if the swelling is above the muscle = swelling same size, but more prominent

- if the swelling is below the muscle = swelling reduce in size, not prominent

- if the swelling within the muscle = swelling increase in size, not prominent

9) Complete examination with examine the patient pulse

if pulsatile = AV malformation

if pulsatile and expansile = aneurysm

Differential diagnosis of swelling

1) compensable swelling = hemangioma

2) mobile sangat = lipoma

3) fixed/not mobile = think of bone so bony exostosis/osteochondroma

4) +ve transillumation = sebacous cyst/ganglion

5) abscess = carbuncle

BTW, patient ni diagnosis die GANGLION.

Please read a bit pasal GANGLION CYST ni.

ADD-ONS

1) cane nak cek compensable swelling tuh?

ans : bile against gravity die berkumpul kat salur darah, so jadi swelling

then bile kita flexed hand, not against gravity.. swelling hilang..

ini namanya compensable swelling..

biasanya hemangioma..

2) Dr Y cakap, as we examine, we must think and came up with differential diagnosis.

ok that's all.