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39 - Examination of skin lesions and lumps
- from Section 10 - Plastic surgery
-
- By Edmund Fitzgerald, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK, O'connor Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Petrut Gogalniceanu, University of Medicine and Pharmacy, Henk Giele, Oxford University Hospitals
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 353-358
-
- Chapter
- Export citation
-
Summary
Checklist
WIPER
• Good light source. Lesion and loco-regional lymph nodes exposed.
Physiological parameters
• Ask: ‘Where is the lesion?’
• Ask: ‘Is the lesion painful?’
System
• S-E-I-S (Site, External, Internal, Surroundings)
Skin type
• Fitzpatrick classification of skin type
Site
• Location of lesion
• Number of lesions
External features
• Size (in cm)
• Shape:
• smooth or irregular edge
• flat or raised profile
• Surface:
• skin: intact or ulcerated skin, skin adnexae
• colour/pigmentation and telangiectasia
• colour distribution: regular vs. irregular
• discharge: blood, pus, lymph
• Scars from previous surgery (skin lesions or lymphadenectomy)
Internal
• Consistency: soft, hard
• Content: gas (crepitus), fluid (fluctuant and transilluminable), solid (nontransilluminable)
• Dynamic interaction: pulsatile, reducible, indentable, compressible
• Mobility and attachment to surrounding structures (above, below and laterally)
• Percussion: dull or resonant (gas, fluid, solid)
• Auscultation: bruits, bowel sounds
Surroundings
• Assess surrounding skin: normal or satellite lesions.
• Palpate for local, regional, general lymphadenopathy.
• Assess nerves: local and distal sensory and motor functions.
• Assess vascular supply of lesion: capillary refill time and pulses.
• Palpate liver for an irregular edge or enlargement and vertebral spine for tenderness if concerned about metastatic deposits.
Examination notes
Tip
The examination of a lump is very poorly done in general, due to a lack of a systematic or anatomical way of approaching the lesion. Palpation in particular needs to be structured as described above in order to avoid redundant gestures.
What is the system for examining a skin lump?
S-E-I-S:
Skin (type) and Site (inspection)
External features (inspection)
Internal features (inspection and palpation)
Surroundings: skin, local, regional or distal lymph nodes (inspection, palpation and movement)
Tip
Beware the melanoma patient with a prosthetic eye or ear.
What are the principal questions in assessing a skin lesion?
• Where is the lesion located on the body?
• What does the lesion look like externally?
• What is inside the lesion?
• What is the anatomical plane of the lesion?
40 - Examination of scars
- from Section 10 - Plastic surgery
-
- By Edmund Fitzgerald O'connor, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, UK, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Henk Giele, Oxford University Hospitals
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 359-361
-
- Chapter
- Export citation
-
Summary
Checklist
WIPER
Physiological parameters
Look
• Anatomy: Site, Orientation, Length, Colour, Contracture
• Healing status: fresh, healing, healed, mature
• Healing method: primary or secondary intention
• Pathological scarring: hypertrophic or keloid changes, scar widening or stretching
• Infection: sinuses, fistulas, granulation or discharge
• Signs of surgical correction (e.g. z-plasty)
Feel
• Tenderness
• Thickness, pliability
• Adherence
• Evidence of malignant occurrence or recurrence
Move
• Mobility of scar
• Mobility and laxity of surrounding skin
• Associated functional impairment (test related muscles, joints and nerves)
To complete the examination…
• Assess regional lymph nodes.
• Obtain formal function assessment by occupational therapist/physiotherapist as required.
Examination notes
How do wounds heal?
Skin scarring is the normal and inevitable outcome of cutaneous wound healing. Wound healing follows a sequence of overlapping phases: haemostasis, inflammation, proliferation and remodelling.
What factor must be considered on inspection?
• Cause: Consider underlying medical comorbidities that led to the scar, but never assume the surgical procedure if this information has not been given.
• Colour: An assessment of the colour of the scar may indicate its age. Wound healing has defined sequential yet overlapping stages within which the scar will change in colour. As a scar passes from the proliferative phase through to remodelling and finally into a mature scar so its colour will decrease in red pigmentation. A variegated pink scar is younger than a homogeneous white scar.
• Location: The position of the scar indicates potential functional complications. If the scar is over a joint there is a risk of contractures causing decreased range of movement. Assess for underlying neurovascular function and deficits following surgery or injury: for example, periorbital scars may be associated with ectropion directly from cicatricial healing, or weakness due to damage to the temporal branch of the facial nerve (CN VII), or a sensory loss due to trigeminal nerve (CN V1) injuries.