DrE: Lumps and bumps Flashcards
Lumps and bumps: Inspection
1) Ensure adequate exposure of lump and surounding region
6Ss
Site - anatomical location
Size - size of base
Shape - shape of base and protuberant
Symmetry
Skin - erythematous/punctum/ulceration
Scars - prvious op
Lumps and bumps: Palpation
Any pain?
Temperature discrepency?
Surface - rough/smooth
Edges - irregular/regular, infiltrative/well defined
Consistency - hard/firm/soft
Tethered - fixed to skin/underlying tissue/muscle (or within muscle)
Fluctuance - Paget’s sign - index & middle finger of one hand at base to stabilise, middle finger of other hand in middle of lump, fluctuant if edges press/spill over tops (x2 planes)
Expansile/pulsatile - index finger of each hand in parrelel on each edge -> movement up and town in vertical plane = pulsatile, horizontal plane = expansile
Transilluminates - shine a light in one side, seen on other side
Reducible - ask patient to reduce it first
Lumps and bumps: Percussion
Lumps and bumps: Auscultation
fluid filled -> fluid thrill/ (in chest) stoney dull
Bowel sounds/bruits
Lumps and bumps: Misc/completion
Lymphadenopathy - comparing with contralateral side
Neurovascular status - ensure no encroachment on nerves/vessels via a distal NV examination
General examination - e.g. for mets
Cosmtic & QoL - Ask patient re impact
Ulcers examination
SITE =
- Venous = gaiter area = medial maleolus
- Arterial = between toes, base of 1st and 5th metatarsals, Heel
SIZE
SHAPE
BEDS
- Base - grannulation tissue/slough/structures e.g. mucle/vessels/bone
- Edge
- Sloping: traumatic/venous
- Punches out: arterial
- Undermined TB
- Rolled: BCC
- Everted: SCC/Marjolin’s
- Discharge: serous, sanguinous, serosangionous, purulent
- Surrounding: cellulitis, excoriations, sensate, LNs
Other: LIMB PULSES + SENSATION AROUND ULCER
Completion:
- Contralateral/further ulcers
- Neurovascular examination incl pulses
- ABPI - note must be >0.8 for compression bandaging
Describe
This is a Venous ulceration
Site: of gaiter area & medial malleolus of left lower limb
Shape: it is irregular in shape
Site: and around 15 by 3 cm in size
Base: It’s base is shallow and there is evidence of healthy granulation tissue with some slough
Edges: and sloping edges
Discharge: ?seropurulent
Suroundings: Haemosiderin deposition & lipodermatosclersosis (HAS LEGS + varicose veins)
Palpation: painless, warm, sensate
Haemosiderosis / Atrophie blanche / Swelling / Lipodermatosclerosis / Eczema / Gaiter ulcers / Stars, venous
Causes of ulcers
- Venous - 75%
- Arterial - 2%
- Mixed arteriovenous - 15%
- Neuropathic
- Pressure
- Vasculitis e.g. Polyarteritis nodosa
- Malignancy e.g. BCC, SCC, marjolin’s
- Systemic e.g. pyoderma gangrenosum
What are the differential diagnoses for a lump?
Classified by location/structures
- Cutaneous
- Benign: actinic keratosis, campbell de morgan spots, dermatofibroma, keratoacanthoma, naevus, seborrhoeic keratosis
- Malignant:
- Epidermal: BCC, SCC, Melanoma
- Dermal: Dermatofibrosarcoma protuberans (DFSP), Malignant fibrosis histiocytoma
- Subcutaneous: Cyst
- Fat: Lipoma
- Artery: aneurysm
- Vein: Varicosity
- Nerve: neuroma
- Lymph node: lymphadenopathy
- Muscle: tumour
- Bone: Tumour, malunited fracture, osteoma
- Anatomical regions e.g.
- Hand - ganglion
- RUQ - liver
- Groin - hernia
Actinic keratosis
- Most common pre-malignant lesion of the skin caused by chronic sun damage
- Common on face
- Present as rough white patches stuck onto an erythematous base
- Histology - thickening of the keratin (hyperkeratosis) & prickle cell (acanthosis) layers of the skin, increased cell mitosis and dysplasis.
- May be considered as a SCC in situ & c.10-15% progress to SCC
Treatment options of actinic keratosis
- Conservative:
- sun protection (prevention is best)
- Medical:
- Disclofenac sodium gel aka solarase
- 5-Flurouracil cream
- Cryotherapy
- Surgical:
- Cautery
- Cryosurgery
- Laser
- Surgical excision
Campbell de Morgan spots:
- Cherry haemangiomas formed by proliferation of dilated venules
- common with increasing age
- seen as small, bright red papules on skin
- Treatment:
- conservative
- rarely medical: cryotherapy
- rarely surgical: curettage, shave excision
Dermatofibroma
- benign neoplasm of dermal fibroblasts or histiocytoma
- common to have history of trauma e.g. insect bite
- presents as firm papule 5-8mm in size & roughly circular within the dermis
- DDx melanoma - due to rapid growth/pigmentation
- ‘Dimple sign’’ - lateral compression -> central dimpling inwards
- Treatment:
- Conservative
- If concern re diagnosis -> excision biopsy
What is a furnuncle & carbuncle?
May affect any hair bearing skin e.g. fact, axilla, groin
- Furnuncle:
- perifollicular bacterial infection by staph sureus -> pus containing swelling/boil
- pus accumulates -> enlargement & punctum
- when punctum bursts furnuncle discharges spontaneously
- Carbuncle:
- cluster of furnuncles that merge -> larger lsion
- often on back of neck in diabetic patient - ALWAYS investigate HbA1c/glucose patients
- Treatment:
- conservative
- occasionally medical: ABx (& treat DM)
- Large & resistant lesion, surgical: I&D
Keratoacanthoma
- benign overgroth of hair follicules with central keratin plug
- spontaneously regress -> scar
- 4-6mo cycle: enlarge in weeks, static for 2-3mo, resolve
Treatment options of keratoacanthoma?
- Conservative:
- frequent monitoing - possibility of malignancy
- Surgical
- Excision biopsy - enables differentiation from SCC
What is a naevus?
Benign proliferation of normal constituent cells of skin
Examples of Naevi:
- Melanocytic:
- Congenital - present at bith, protuberunt, hairy/pigmented (light-dark brown), >1cm in diameter. Risk of developing malignancy <5%
- Junctional: flat, round, oval pigmented (light-dark brown) macules that are often multiple. 2-10mm
- Intradermal: dome-shaped, flesh coloured papules, face/neck
- Compound: pigmented nodule - warty/hairy with radiable pigmentation, <1cm
- Blu: solitary, blue
- Becker’s: pigmented hairy naeus, back/shoulder
- Dysplastic: irregular shape & pigmentation, high risk of malignant change
- Vascular:
- Port wine stain: irregular red/pueple macule, often 1 side of fact
- Salmon patch: c.50% neonates, patches on face often disapear, posterior patch (stork marks) often persist
- stawberry naevus: capillary haemangioma, 1st few weeks of life -> max size @1yr, fleshy, red naevus, regress spontaneuously by 8 yrs -> area of atrophy
- Epidermal:
- warty naevus: linear, pigmented warty lesion -> several cm, recurrence common post surgical excision
- Connective tissue:
- shagreen patch - rare soft yellow connective tissue naevus assoc with tuberose sclerosis - lumbar/sacral region
What is Seborrhoeic Keratosis?
Benign overgrowth of basal cell layer of epidermis
Following histological features:
- Hyperkeratosis: thickerning of keratin layer
- Acanthosis: thickening of prickle cell layer
- Hyperplasia: increased division of variably pigmented basaloid cells
Serborrheoic keratosis
- often on face @& trunk
- variably pigmented lesion with stuck on skin warty appearance
- Numerous, scratch off easily & bleed
- Benign
- Discomfort, irritation
- Treatment:
- Usually Conservative
- Medical: cryotherapy,
- Surgical: curretage, cautery
What is neurofibroma?
- Benign hamartoma of peripheral nerve schwann cells
- soft, fleshy, pedunculated lesions of skin, gelatinous, violaceous nodules
- Altered sensation, pain, compressive symptoms may be present e.g. intra-abdo -> bowel obstruction & impingelemt of spinal column -> scoliosis/bone cysts
- Treatment:
- Conservative
- Surgical - excision
What is neurofibromatosis?
2 similar Autosomal Dominant conditions
- Type I = Von Recklinghausen’s Disease
- >=6 cafe-au-lait spots >=0.5cm diam
- multiple cutaneous neurofibromas that may be v large & can undergo sarcomatous change
- increased risk of meingioma, acoustic neuroma, optic nerve gangioma
- Kphosis & bowing of tibia
- Type II = Bilateral Acoustic Neurofibromatosis
- Bilateral acoustic neurofibromas
- Intracranial memingiomas
- Cranial nerve schwannomas
Papilloma aka skin tag
- Benign overgrowth of all layers of skin with vascularised core, fleshy, vary in size
- Often face & neck
- TreatmentL surgical excision
Pyogenic granuloma
- Acquired capillary haemangioma
- Assoc with Hx of trauma
- Soft raised lesion, light red to deep purple
- Painful & can bleed
- Management:
- Surgical - excision - reduced wisk of bleeding & histological diagnosis
WARNING - looks like amelanotic melanoma - particularly if subungal
What is a sebacrous (epidermoid) cyst?
Abn membranes line sac composed of epitherlial cells containing caseous sbstance composed of: fibrous tissue, fluid, keratin
Sebaceous cyst
- fixed to skin, variable size with central punctum, discharge/unceration/infection (aka abscess)
- Treatment
- conservative
- If symptomatic, surgical excision i
Lipoma
- benign tumour of mature fat cells
- Commonly seen on neck, trunk,
- neither fixed to skin or underlying structures, freely mobile -> slip sign
- Treatment
- Conservative
- Surgical:
- liposuction - less scaring but more recurrence
- excision biopsy
What is an ulcer?
a breakdown in all layers of an epithelial surface
What are the causes of ulcers? (& edge type)
- Traumatic:
- ill fitting shoes/pressure sores
- E: sloping
- Venous:
- deep venous insufficiency & venous hypertension, ?malleoli
- E: sloping
- Infective:
- primary/secondary to infection of colonised chronic ulcer by e.g. staphylococcus/streptococcus
- E: sloping
- Arterial:
- painful, peripheral arterial disease, pressure points e.g. toes/planter surface of foot/heel/metatarsal heads. ?emolism/vasculitis
- E: punched out
- Neuropathic:
- painless, DM/Chronic ETOH/leprosy/syphilis
- E: punched out
- Neoplastic:
- Primary/secondary
- E: everted - SCC/marjolins, rolled - BCC
Treatment option for ulcers
- Conservative
- Dressing
- foot elevation
- orthopaedic foot wear
- compression stockings - contraindicated if peripheral arterial disease i.e. ankle brachial pressure <0.8
- Medical
- Treat underlying cause/optimis e.g.
- antibiotics
- diabetic control
- Treat underlying cause/optimis e.g.
- Surgical:
- VV - stripping and ligation
- Neoplastic - surgical excision
- Skin graft
