Swelling and ulcers examination

CLINICAL EXAMINATION OF A PATIENT WITH AN ULCER OR A LUMP (swelling)

Ulcer : It is adiscontinuity in the epithlium surface.

Clinical examination of an ulcer

1-The Situation of the Ulcer


Many ulcers occur in characteristic situations, for example the rodent ulcer at the side of the nose and beneath the eye, and the carcinoma of the tongue at the side of the tongue. Some indication of the nature of an ulcer may be obtained from its situation alone.


2. Is the Ulcer Single or Multiple? 3. Note the Size of the Ulcer 4. Examine the Shape of the Ulcer: Ulcers may be round, oval, irregular, punched-out, etc. 5. Note the Base of the Ulcer: The base of an ulcer may be indurated, soft, or fixed to deeper structures. Marked induration or fixation to deeper structures may be indicative of malignancy.

6. The Floor of the Ulcer may be covered by:

a. Granulations. These may be red, pale, or flabby and may or may not bleed. b. The floor may be smooth. c. It may be covered with slough, membrane, etc. d. The floor may be adherent to soft parts or bone. e. The floor may be fungating as seen in some clinical varieties of malignant disease.


a. Undermined (as seen in tubercular ulcers). b. Punched-out (as found in gummatous ulcers). c. Rolled (as characteristically occurs in rodent ulcers). d. Rolled, raised, and everted (as characterized by malignant ulcers).

8. The condition of the parts surrounding the ulcers must be examined

They may be inflammed, healthy, oedematous, pigmented and, in some instances, the adjoining area may have impaired sensation. 9. If there is a discharge from the ulcer? its colour, and smell should be noted and a bacteriological smear taken for culture.

10. Is the Ulcer Painful?

Inflammatory and traumatic ulcers are usually painful ,tuberculous ulcers in the mouth are often very painful, but in the early stages most malignant ulcers are painless. However, when the malignant ulcer becomes established and increases in size it become discomfort.


Be cautious about handling ulcers with ungloved fingers. Always wash your hands well after examining an ulcerated mouth.

THE EXAMINATION OF A LUMP (SWELLING)

Before carrying out a local physical examination of any lump or mass it is essential to examine the following: 1. How long the swelling has been present? 2. Whether it is getting larger!. 3. Whether there is any possible cause for the swelling, i.e., trauma, etc.

The local examination of the lump is concerned, the most important facts are as follows:

The Exact Anatomical Situation of the Mass Lumps may arise from skin, subcutaneous tissues, muscle, tendon, nerve, bone, blood-vessels, or an organ, and if the examiner is unable to detect the exact structure from which the mass arises then any attempt at differential diagnosis is inaccurate.

For example, a swelling at the angle of the mandible may appear to originate from the hard tissues and the clinician will consider the possibility of a cyst, ameloblastoma, etc., when, in fact, the lump is arising from the soft tissues and is, indeed, a sarcoma of the masseter muscle. Deciding the exact anatomical location of any mass or swelling is probably the most important single step taken in the physical examination and diagnosis of a lump.


Whenever a lump or mass is examined, careful palpation of the associated lymph-nodes must be carried out. This important step must never be omitted. In fact, in the clinical investigation of an oral lesion, it is prudent to examine the cervical nodes first before inspecting the mouth. The tender enlarged lymph-nodes associated with an inflammatory process are readily differentiated from the rock-hard nodes of a metastasizing malignancy.

3. Is the Swelling Single or Multiple? 4. The Shape. 5. The Size. 6. The Surface of the Mass: The surface of a mass may be smooth, lobulated, or irregular. 7. The Edge: The edge of a lump may be clearly defined or diffuse, blending with the surrounding tissues as do most lumps or masses of inflammatory origin.

8. The Consistency

The consistency of lumps or mass is defined as Compressability it may be soft, as in the case of the lipoma; firm which is the consistency of a fibroma; cartilage hard, as in the pleomophic adenoma; bony hard, as in the osteoma; rock hard, as malignant lymphatic nodes; rubbery hard, which is the classic description of the, consistency of the affected nodes in Hodgkin's disease.

9. Is the Lump Tender or Warm on Palpation?

Tenderness on gentle palpation is important physical sign, for while it can be elicited with inflammatory lumps, neoplasms are commonly painless unless they just happen to be secondarily infected. The site of an acute inflammation is usually warmer than the adjacent areas.

10. Is the Lump Attached to the Skin?

During the physical examination of a lump an attempt should be made to move the skin over the lump to ascertain if the skin is tethered to it. The skin overlying an abscess may be fixed firmly to the inflammatory mass and a similar condition may occur with superficial malignancies.


11. Is Fluctuation Present?
Fluctuation is a physical sign indicating the presence of fluid within a lump. It is elicited by placing the tips of two fingers on the lump. When pressure is applied to the mass with one finger, a transmitted upward impulse is felt with the other finger-tip. +ve fluctuation -------- aspiration Blood----hemangioma or infected cyst Yellowish greyish offensive odor----abcess White without odor-----odontogenic cyst


The classic signs of heat, redness, swelling, and pain are indicative of either an inflammatory swelling or secondary infection in a non-inflammatory mass. 13. Transillumination This test rarely (can sometimes be applied to nasolabial cysts).

14. Does the Lump pulsate?

There are three types of pulsation which may occur in lumps: a. The mass may be pulsatile, i.e., the entire mass pulsates. This is best example is aneurysm. b. Transmitted pulsation occurs when the mass rests on a large artery. When such a mass is palpated, an impulse is felt which is transmitted from the artery. Salivary adenomas in the palate may sometimes transmit the pulsation of the greater palatine artery. c. A mass lying deep in the tissues may displace an artery so that it lies superficially upon the mass. On palpation the mass will appear to pulsate, in fact, palpating an artery.

a. Arteries: Pressure on the arteries is evidenced by diminution of the pulse and in extreme cases by coldness of the dependent part and eventually by gangrene. b. Veins: Pressure on veins may produce cyanosis and oedema on the distal side of the vessel. c. Nerves: Pressure on nerves may produce paraesthesia, anaesthesia, or paralysis, etc. d. Adjacent organs: Pressure may be exerted by a mass on any adjacent organ. In the head and neck two structures commonly affected in this way are the trachea and the oesophagus, with resultant respiratory problems and dysphagia.

This may be a helpful diagnostic sign. Reddening may suggest an inflammatory aetiology, while a bluish swelling which blanches on pressure is most probably a haemangioma.