Ward Round

Last week I went to follow ward rounds 3-4 times but i was too lazy for the whole lat week. It wasn't productive at all. *REGRET* I spent most of time watching anime, reading manga and murakami's novel...with thickness of Merck's manual which was impressive. It was all because of the flood and oncall attendance, I had to cancel my plan to go back to taiping for two consecutive weekends, I lost my mood and motivation already. Sounds gedik but honestly I missed my nephew A LOT, that was why.

But yeah, my motivation was recharged now. *But I scrolled through online shoppe with my roomate yesterday. Great*

Lat week there were lots of patients got admitted bacause of lump, hemorrhoid, abcess, So, I got the chance to learn on the management and how to examine these patients with a specialist and some housemen ( Most of them were my seniors, we were in a medic futsal team, owyeahh). I was the only student yang sesat follow another ward round that time, The Heck.

Usually, as a student, it is improtant to be able to describe a lesion be it ulcer, rashes or lump by inspection. One of the HO (futsal teammate) said lump and bump are the common questions which might come up as short notes. Here I'll be focusing on the local examination. But in practice, Don't forget the general examination as well.

1. Site

well, you can actually divide the gluteal part into quadrants just like breast examination but of course there would be no nipple. If you see a patient with nips on the butt, please contact NASA immediately. Or pilonidal cyst can occur just above the gluteal cleft. Would be much better if you can measure the lesion from a bony point, but I was not that good when I got panicked. So I preferred the first option.

2.  size, depth, height

On gluteal, it is recommended that you describe the size by measuring it instead of comparing with size of grape, egg or whatever it is in physical examination. But it is acceptable in history taking. Like in ulcer we can measure the depth...And there was once I saw a doctor presented a case of bump, they even mention the height!!!!

3. shape

I'm not really sure on this, but in browse, it acceptable student want to liken the shape to kidney or pear. Hmm...

4. surface

smooth, bosselated, rough, fungating.

5. color

• erythematous = infection, inflammation
•  purplish = thrombosed, congestion

6. temperature

Assess the skin temperature with the dorsal surfaces of your fingers.

7. tenderness
Is the lump tender? Which parts are tender? Always try to feel the non-tender part before feeling the tender area, and watch the patient’s face for signs of discomfort as you palpate.

8. edge

clearly defined or not.

9 composition

• consistency, hard, firm, soft
• fluctuation
• translucence
• resonance
• pulsatility
• compressibility
• bruit

10. reducibility

11. relation to surrounding structure

Attachment to deeper structures is more difficult

to determine.Underlying muscles must be tensed to

see if this reduces the mobility of an overlying lump

or makes it easier or less easy to feel. The former

indicates that the lump is attached to the fascia covering

the superficial surface of the muscle or to the

muscle itself; the latter that the lump is within or

deep to the muscles. Lumps that are attached to

bone move very little. Lumps that are attached to or

arising from vessels or nerves may be moved from

side to side across the length of the vessel or nerve,

but not up and down along their length. Lumps in

the abdomen that are freely mobile usually arise

from the intestine, its mesentery or the omentum.

-Browse-

12. regional lymph node


13. Discharge is very important.

• pus
• active bleeding
• smell, color
• punctum

There was a patient, there was a swelling measured about 8x4 cm, tender, erythematous margin, fluctuant, warm, with pus discharge from the cente sited at inner quandrant of left gluteal. It was indurated as well. So, the impression was gluteal abcess, and the patient had ultrasound done to rule out any deep seated gluteal abcess. It is acceptable to say that the pus charge is minimal if you can see there is pus seen at the punctum.

And another patient came with on-off puss. he drained it himself at home. It was actually an infected pilonidal sinus with multiple sinus opening. And he was informed on admission that he actually need to undergo surgery to remove it. He was not expecting that. And after the ward round, I went to clerk this patient and asked his permission to look at his file. He said, "boleh je, nak examine yang betul punya pun boleh, panggil lah kawan sorang. " He was a cooperative person. May Allah cure him :)

***

We had a class with Mr Nazli once on Lump, Bump, Groin.  He really stress us to understand the histological structure of the skin that we will be able to understand the pathology hence distinguishing the origin and character of the bumps. Need to do revision on that later.

http://vbil.bioen.illinois.edu/OCT/OCT_content4_clip_image003.jpg