hand examination (with hemangioma case) by 'Aliah

salam

this case was discussed 2 times, 1st during grand ward round, the other one was during Mr Amin's teaching with his mentee, di mane aku sibuk2 nak join jgk. sy tukang tulis blk je di sini, smg kite sume dpt manfaat bersame. it happened at ward 2A.

c/o: 40 years old Malay lady presented with painful swelling of right ring finger. please examine her.

1) Position

Mr Amin said the most important for hand examination is to position both hands correctly. put the hands on top of a pillow with the patient in sitting position. ask the patient to abduct the fingers as maximum as she can because from this position, we can already detect any neurological disorder related to the hands, specifically motor disorder.

2) Inspection (look)

inspection is divided into 2, towards the pathology (mass) itself, as well as towards the hand as a whole. 1st, compare both hands, don't take too much time doing this, just inspect surfacely because the examiner can be annoyed if korang sibuk2 nak pegang2 ke, angkat2 ke, or give excessive attention to the normal hand.

then, check for any signs of wasting or skin discoloration, or any obvious changes related to the hand.

for the mass or swelling, inspect it just like you inspect any lump and bump in surgery. do not forget to include the edge, border, size, site, character of the mass (fungating, etc), surface, and any discharge noted. for the site, describe precisely where is the origin of the mass. don't forget to check fo any associated deformity, such as nail deformity or finger deformity.

3) Palpation (feel)

begin with soft palpation, in order to detect any tenderness associated with the mass, xkesahlah at the mass itself or the area surrounding the mass. then, don't forget to check for circulatory status, i.e. CRT and pulse, as well as the sensation whether it is intact or not.

4) Movement (move)

for movement, just test for active movement first and examine the ROM. assess the ROM of all fingers of the hand, not just the affected finger, because others can be affected too. for example, ring finger share the same tendon with the little finger, so, if one is affected, the other might be affected too.

5) Ending

complete your examination by checking the lymph node, other features of malignancy, or any relevant examination related to your differentials.

now, let's go to the case:

c/o: 40 years old Malay lady presented with painful swelling of right ring finger. please examine her.

presentation:

on general inspection, the patient is alert and concious. she is not ill neither in pain.

on inspection, there is a mass arises beneath the nail of the right ring finger. the mass is fungating in nature with an irregular edge and uncircumscribed border. the margin is raised and the surface and consistency are hard. there is no discharge or blood or pus seen. it is associated with skin discoloration around it, nail deformity of the same finger, and also wasting of dorsal interossei m/s of the same hand. on palpation, the mass is warm and tender. upon movement, there is reduced ROM of both ring and little finger of the same hand.

i want to complete my examination with checking the related lymph nodes as well as to examine the other features of malignancy.

the ddx:
1) wartz
2) Squamous cell ca the finger
3) infected melanoma
4)TB of the phalanx
5) severe fungal infection
6) melanic features of leukaemia