Approach

• Description of Lump
• Spot diagnosis
• Should The Children Ever Find Lumps Readily

1. S - size / site / shape / surface / skin / symmetry / scars
2. T - temperature / tenderness / transilluminability
3. C - Colour / Consistency / Compressibility
4. E - edge / expansibility / pulsatility
5. F - fluctuation / fluid thrill / fixation
6. L - lymph nodes / lumps elsewhere
7. R - resonance / relations

• Ulcer: BEDD

1. B - base
   • Presence of granulation tissue
   • Slough
   • Evidence of malignant change
2. E - edge
   • Sloping: a healing ulcer (venous or traumatic)
   • Punched out: ischaemic or neuropathic
   • Undermined: pressure necrosis or TB
   • Rolled: basal cell carcinoma
   • Everted: squamous cell carcinoma
3. D - description of structure at base
   • Fascia
   • Muscle
   • Bone
4. D - discharge
   • Serous (clear)
   • Sanguinous (blood)
   • Serosanguinous
   • Purulent (infected)

Inspection

1. Site
   • Measured with respect to a fixed landmark (other bony prominence)
2. Size
   • Measure size in centimetres
3. Shape
4. Skin
5. Symmetry
6. Scars
7. Colour

Palpation

1. Surface
   • Smooth/irregular
2. Edge
   • Well/poorly defined
3. Consistency
   • Soft - flesh of nostrils
   • Firm - nasal septum
   • Hard - bridge of nose
4. Temperature
   • Using the dorsal surface of the hand
5. Tenderness
6. Transilluminability
   • Pen torch on either side of lump
   • Look through "opaque" tube (like a smarties tube)
7. Pulsatility
   • Place fingers both sides of lump
   • Expansile / pulsatile
8. Compressibility / reducibility
   • Compressible: lump disappears on release (AV malformations)
   • Reducible: lump disappears on pressure but reappears when another oppising force is applied
9. Fluctuations
   • Place fingers on opposite sides of lump
   • Repeat at right angles
10. Fluid thrill
11. Fixation
    • Determine which plane lump is in and which structures it is attached to
    • Skin: moves skin over lump
    • Muscle

Percussion

1. Dull
2. Resonant (indicates air)

Auscultation

1. Bruits
2. Bowel sounds

Additional

1. Examine draining lymph nodes
2. Neurovascular status of area/limb
3. Look for other lumps
4. General examination (as necessary)

Comparison of different types of leg ulcers

	Venous	Ischaemic	Neuropathic
Appearance
Site	Gaiter region	Tips of toes / pressure areas	Heel. underneath metatarsal heads (pressure bearing areas)
Shape	Variable, irregular	Regular outline	Regular outline
Size	Can be very large	Varying size	Several cm
Edge	Sloping, pale purple/brown	Punched out, clean	Clean
Base	Pink granulation tissue	Bone may be exposed, no granulation tissue	Often exposed bone
Surrounding skin	Chronic venous signs; lipodermatosclerosis	Grey/blue	Normal
Skin temperature	May be warmer	Cold	Normal
Pulses	Present	Absent	Present