Physical Examination: Metastatic Nodule

Questions

This is 60 years old gentleman with known case of cancer head of pancreas and undergone Whipple procedure 3 years ago. Currently he presented with increasing in lethargy, loss of appetite and reduce weight. Examine the Gastrointestinal system and tell me the provisional diagnosis.

General Examination

Before proceeding with specific examination, you should do a very quick general inspection and examination. look at patient general condition, mental status whether he is well alert and conscious or not, functional status of the patient,  hydrational and nutritional status, signs of chemo / radiotherapy side effects. Examine also any peripheral sign of gastrointestinal problem like bleeding tendency or stigmata of liver disease, any clubbing or leukonychia. any flapping tremor.

Then proceed with examination of the abdomen. Starting with inspection then proceed with palpation, percussion and auscultation.

Inspection

On inspection, the exposure is not adequate. By right he should be exposed well from the nipple line to the mid thigh. But for patient's modesty, then the exposure is acceptable. Patient appears to be cachexic. The abdomen is flat with upper midline incision scar. It is well healed with keloid formation. There is presence of mass at the right subcostal region measuring about 3X3 cm, rounder, regular margin, no skin changes, no punctum and there is presence of dilated vein below it. Apart from that, there is no hyperpigmentation of the abdomen, no other surgical scar, no other dilated vein and no visible peristalsis. Do not forget to ask patient to cough to look for inguinal and incisional hernia.

Palpation

You should palpate the abdomen and then examine the lump. Look for any hepato splenomegally or any other palpable nodule. In this patient, he actually have another two small subcutaneous nodule underneath the incisional scar. The scar should also be examined for it's integrity and hernia that is not well visualized upon cough impulse. Then ballot the kidney. Next is to examine the lump. In this patient, the lump is firm to hard in consistency, not fixed to the skin, non mobile, fixed to the underlying structure, non tender and the translumination test is negative.

Percussion

To look for any ascites or any underlying mass.

Auscultation

Listen for the bowel sound, any bruit.

Complete the Examination.

To complete the abdominal examination, you should inform the examiner to do the per rectal examination. In this case, you must also completing the examination by doing the respiratory examination and genitourinary examination.

Provisional Diagnosis.

The diagnosis for this patient is Recurrence of Ca Head Of Pancreas with subcutaneous nodular metastasis. To confirm your finding, you should order of CT TAP (Thorax, Abdomen, Pelvis) and do the histopathology examination (FNAC or Trucut biopsy from the mass).