1. POWER
POINT
CLINICS

2. DR.M.RAVI CHANDRA,M.S(G.S)
ASST. PROF. OF SURGERY
RIMS SRIKAKULAM

3. INSPECTION
 1. SITE- EXACT ANATOMICAL LOCATION
IMPORTANT AS SOME SWELLINGS OCCUR
IN A TYPICAL POSITION WHICH IS
DIAGNOSTIC
 EXAMPLES
 POST AURICULAR DERMOID-BEHIND EAR
 EXTERNAL ANGULAR DERMOID –LATERAL END
OF EYE BROW
 MENINGOCELE- OVER THE BACK IN MIDLINE

4. EXTERNAL ANGULAR DERMOID
*Image via Bing

5. EXTERNAL ANGULAR DERMOID
*Image via Bing

6. *Image via Bing

7. SUB MANDIBULAR DERMOID
*Image by 12498905@N02 via Flickr

8. *Image by 48276084@N00 via Flickr

9. DERMOID CYST OF SCALP
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10. DERMOID CYST IN MID LINE
*Image via Bing

11. ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW
*Image via Bing

12. *Image via Bing

13. MENINGOCELE
*Image via Bing

14. HUMAN TAIL?
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15. 2.NUMBER
 USUALLY SINGLE , SOME TIMES MULTIPLE
 MULTIPLE EXAMPLES
 MULTIPLE NEUROFIBROMATOSIS(VON RECK
LING HAUSENS DISEASE)
 MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)
 DIAPHYSEAL ACLASIS
 HYDRADENITIS SUPPURATIVA
 MULTIPLE LYMPHOGLANDULAR SWELLINGS

16. *Image via Bing

17. *Image via Bing

18. MULTIPLE LIPAMATOSIS
*Image via Bing

19. HYDREDENITIS SUPPURATIVA OF AXILLA
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20. *Image via Bing

21. *Image via Bing

22. EXTEXNSIVE SCARRING UNDER THE ARMS DUE TO
HYDREDENITIS SUPPURATIVA
*Image via Bing

23. 3.SHAPE
 SPHERICAL
 OVOID
 KIDNEY /BEAN SHAPED/RENIFORM
 IRREGULAR

24. 4.SIZE

25. 5.SURFACE
 COLOUR
 SPECIAL CHARACTER OF SURFACE
 OVERLYING SKIN

26. A)COLOUR
 ARTERIAL HAEMANGIOMA – BRIGHT RED
 VENOUS HAEMANGIOMA— PURPLE
 MALIGNANT MELANOMA- BLACK
 BENIGN NAEVUS – BLACK
 RANULA –BLUE

27. CAPILLARY HAEMANGIOMA OVER FORE HEAD
*Image via Bing

28. BENIGN NEVUS

29. BENIGN NEVUS
*Image via Bing

30. HERIDITARY DYSPLASTIC NAEVUS SYNDROME
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31. *Image via Bing

32. MALIGNANT MELANOMA
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33. *Image via Bing

34. MALIGNANT MELANOMA OF FOOT
*Image via Bing

35. RANULA
*Image via Bing

36. *Image via Bing

37. RANULA OF RIGHT SUBLINGUAL
*Image via Bing

38. b)Character of surface
 TWO CHARACTERISTIC SURFACES ON
INSPECTION
 CAULIFLOWER SURFACE – SQUAMOUS CELL
CARCINOMA
 FILIFORM BRANCHED SURFACE – PAPILLOMA
(IRREGULAR NUMEROUS BRANCHED SURFACE)

39. SQUAMOUS CELL CARCINOMA
*Image via Bing

40. *Image via Bing

41. SCC OF TONGUE
*Image via Bing

42. FILIFORM SURFACE OF PAPILLOMA
*Image via Bing

43. INDONESIAN TREE MAN
*Image via Bing
H.P.V. AFFECTING HANDS &LEGS

44. c)Skin over lying swelling
 TENSE , SHINY WITH PROMINENT VEINS – SARCOMA
 RED &EDEMATOUS – INFLAMMATORY
 BLACK PUNCTUM – SEBACEOUS CYST
 PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS
 SCAR
 PREVIOUS OPERATION(REGULAR SCAR WITH SUTURE
MARKS)
 INJURY(REGULAR SCAR)
 SUPPURATION(PUCKERED ,BROAD &IRREGULAR)
 PEAU - D ORANGE APPEARANCE(MAINLY IN CA. BREAST)
 ULCERS

45. ABSCESS
*Image via Bing

46. ABDOMINAL WALL ABSCESS
*Image via Bing

47. NASAL ABSCESS
*Image via Bing

48. INFECTED SEBACEOUS CYST WITH PUNCTUM
*Image via Bing

49. SOFT TISSUE SARCOMA
*Image via Bing

50. *Image by 88761406@N00 via Flickr

51. *Image via Bing

52. 6.VISIBLE PULSATIONS
 PULSATION
 A MOVEMENT OR INCREASE IN SIZE
SYNCHRONOUS WITH EACH HEART BEAT
 2 TYPES
 EXPANSILE PULSATIONS – SWELLINGS ARISING
FROM ARTERIES EX: AORTIC ANEURYSM ,
CAROTID BODY TUMOUR
 TRANSIMITTED PULSATIONS – SWELLINGS
CLOSE TO ARTERIES
 REMEMBER NOT TO TOUCH THE PATIENT
DURING INSPECTION

53. 7.VISIBLE COUGH IMPULSE
 PERFORMED WHEN SWELLING IS OVER
ABDOMEN,CHEST,SPINAL CANAL OR
CRANIUM
 COUGH IMPULSE
 VISIBLE INCREASE IN THE SIZE OF SWELLING
SYNCHRONOUS WITH COUGH
 POSITIVE IN SWELLINGS COMMUNICATING
WITH ABDOMEN,THORACIC
CAVITY,SPINAL CANAL OR CRANIAL
CAVITY

54. POSITIVE COUGH IMPULSE
 HERNIA
 MENINGOCELE
 VARICOCELE
 SAPHENA VARIX
 IN CHILDREN CRYING ACTS AS COUGHING

55. 8.VISIBLE PERISTALYSIS
 OBSERVED IN ABDOMINAL LUMPS AND
INGUINAL SWELLINGS
 CONGENITAL HYPERTROPHIC PYLORIC
STENOSIS – VISIBLE GASTRIC
PERISTALYSIS
 INGUINAL HERNIAS (ENTEROCELE)
INTESTINAL PERISTALYSIS
 LUMPS DUE TO INTESTINAL MALIGNANCY
PERISTALYSIS IS SEEN

56. 9.MOVEMENT WITH
RESPIRATION
 SEEN IN ABDOMINAL LUMPS
 SWELLINGS ARISING FROM
 STOMACH
 LIVER
 SPLEEN
 GALLBLADDER
 HEPATIC FLEXURE OF COLON
 SPLENIC FLEXURE OF COLON
 RENAL LUMP THOUGH NOT IN CONTACT WITH
DIAPHRAGM ,MOVES WITH RESPIRATION

57. 10.Movement with deglutition
 IN CASE OF NECK SWELLINGS
 SWELLINGS MOVING WITH DEGLUTITION
 THYROID SWELLING
 THYROGLOSSAL CYST
 THYROGLOSSAL FISTULA
 SUBHYOID BURSA
 PRE/PARA TRACHEAL LYMPH NODES
 EXTRINSIC CARCINOMA OF LARYNX

58. WHY THYROID MOVES UP WITH DEGLUTITION?
 THYROID IS ENCLOSED IN PRETRACHEAL
FASCIA
 PTF ATTACHES TO THYROID &CRICOID
CARTILAGES(BERRY’S LIGAMENT)
 SUPERIOR CONSTRICTOR MUSCLE
CONTRACTION DURING DEGLUTITION
 THESE CARTILAGES MOVE UP
 ALONG WITH THESE THYROID MOVES UP

59. 11)MOVEMENT WITH TONGUE PROTRUSION
 IN CASE OF MID LINE NECK SWELLINGS
 EG:THYROGLOSSAL CYST &FISTULA
 WHY?
 ATTACHED TO FORAMEN CAECUM OF TONGUE

60. 12)PRESSURE EFFECTS
 WHEN SWELLING IS PRESENT ON LIMBS
 AN AXILLARY SWELLING WITH LIMB EDEMA –
LYMPHNODAL SWELLING
 PARESIS – PRESSURE ON NERVES
 WASTING OF MUSCLES OF DISTAL LIMB-
TRAUMATIC SWELLING(WASTING DUE TO
NON-USE/INJURY TO NERVES)
 SWELLING IN NECK WITH VENOUS
ENGORGEMENT(RETROSTERNAL EXTENSION)

61. PALPATION
 DEFINITE CLUE TO DIAGNOSIS
 METHODICAL,FOLLOW DEFINITE ORDER
 BE GENTLE
 SHOULD NOT HURT THE PT.

62. 1.TEMPERATURE
 IT IS AN ABSOLUTE STANDARD PRACTICE
TO TEST FOR TEMP FIRST-WHY?
 BEST FELT BY BACK OF THE HAND-WHY?
 INCREASED IN
 INFLAMMATORY SWELLING
 WELL VASCULARISED TUMOURS- SARCOMA

63. 2.TENDERNESS
 PAIN DUE TO PRESSURE EXERTED OVER
THE SWELLING IS TENDERNESS
 PALPATE GENTLY OVER ALL THE AREA
 IT IS A SIGN
 FEATURE OF
 INFLAMMATORY SWELLINGS
 SWELLING RELATED TO NERVES
-NEUROFIBROMA

64. 3.SIZE& SHAPE
 CONFIRM VERTICAL & HORIZONTAL
DIMENSIONS
 NOTE THE THIRD DIMENSION DEPTH
WHICH COULD NOT BE EXACTLY
DETERMINED BY INSPECTION

65. 4.SURFACE
 WITH PALMAR SURFACE
 SMOOTH –CYSTIC SWELLINGS
 LOBULARWITH SMOOTH BUMPS-LIPOMA
 NODULAR –MULTI NODULAR GOITRE/MATTED
LYMPH NODES
 IRREGULAR - CARCINOMA

66. SMOOTH SURFACE OF A SEBACEOUS CYST
*Image via Bing

67. *Image via Bing

68. M..N.G. WITH NODULAR SURFACE

69. 5.EDGE
 1)WELL DEFINED & REGULAR – BENIGN
NEOPLASMS
 2)WELL DEFINED & IRREGULAR –
MALIGNANT NEOPLASM
 3)ILLDEFINED &DIFFUSE –INFLAMMATORY
SWELLINGS

70. ABSCESS WITH ILL DEFINED MARGINS
*Image by 9085776@N08 via Flickr

71. LIPOMA WOTH WELL DEFINED MARGINS
*Image by 72310117@N07 via Flickr

72. LARGE LIPOMA WITH WELL DEFINED MARGINS
*Image by 78523246@N00 via Flickr

73. *Image by 78523246@N00 via Flickr

74. IRREGULAR BORDERS IN CARCINOMA BREAST
*Image via Bing

75. SLIP SIGN
*Image via Bing
 TO DEFFERENTIATE BETWEEN LIPOMA
AND CYSTIC SWELLING(BOTH HAVE WELL
DEFINED ,REGULAR BORDERS)
 WHEN EDGE OF A SWELLING IS PALPATED
WITH A FINGER ,IF IT SLIPS UNDER THE
FINGER,. DOES NOT YIELD TO IT , IT IS A
LIPOMA,IF IT YIELDS TO FINGER IS A CYST

76. 6.CONSISTENCY
 SOFT – LIPOMA
 CYSTIC- CYSTS &CHRONIC ABSCESSES
 FIRM –FIBROMA
 HARD BUT YIELDING-CHONDROMA
 BONY HARD-OSTEOMA
 STONY HARD- CARCINOMA
 VARIABLE CONSISTENCY- MALIGNANCY

77. HOW TO ASSESS CONSISTENCY
 SOFT – EAR LOBULE,ALAE OF NOSE
 FIRM- TIP OF NOSE,UN CONTRACTED
MUSCLE
 HARD -BRIDGE OF NOSE,CONTRACTED
MUSCLE

78. SIGN OF MOULDING OR
INDENTATION
 LOOK FOR THIS SIGN IN SOFT &CYSTIC
SWELLINGS
 PRESS A FINGER INTO SWELLING FOR 1-2 MTS
AND RELEASE IT IF SWELLING REMAINS
INDENTED IT INDICATES PRESENCE OF
PULTACEOUS MATERIAL(PUTTY LIKE)
 SEEN IN
 1.SEBACYOUS CYST
 2.DERMOID CYST
 3.COLONIC MASS WITH FAECAL MATTER

79. PAGET’S TEST
 DONE FOR SMALL SWELLINGS TO KNOW
THE CONSISTENCY(CYSTIC/SOLID)
 THE CENTRE AND PERIPHERIES ARE
PALPATED WITH INDEX FINGER
 CYSTIC SWELLING FEELS SOFTER AT CENTRE
THAN PARIPHERY
 SOLID SWELLING FEELS FIRMER ATCENTRE
THAN PERIPHERY

80. SPECIAL TESTS
 DONE IN CASE OF SOFT/CYSTIC SWELLING
 7.FLUCTUATION
 8.TRANSILLUMINATION
 9.COUGH IMPULSE
 10.REDUCIBILITY
 11.COMPRESSIBILITY
 IN SOLID SWELLINGS DIRECTLY PROCEED
TO TEST FOR RELATION TO OTHER
STRUCTURES

81. 7.FLUCTUATION
 TRANSMISSION OF IMPULSE IN TWO
DIRECTIONS AT RIGHT ANGLES TO EACH
OTHER
 IMPLIES PRSENCE OF FLUID IN THE
SWELLING

82. HOW TO ELICIT FLUCTUATION?
 IF THE SWELLING IS MOBILE FIRST FIX IT OR
ASK THE ASST. TO HOLD IT
 KEEP 2 INDEX FINGERS ON OPPOSITE POLES
 WHEN ONE FINGER IS PRESSED THE FINGER
AT OPPOSITE END FEELS THE IMPULSE &
PASSIVELY LIFTED UP
 REPEAT THE MANUVERE IN A PLANE AT RIGHT
ANGLES TO THE 1ST ONE
 IF IMPULSE IS FELT IN BOTH PLANES IT IS A
POSITIVE FLUCTUATION TEST

83. LAW BEHIND FLUCTUATION!
 PASCAL’S LAW
 PRESSURE EXERTED TOA FLUID IS TRANSMITTED
EQUALLY IN ALL THE DIRECTIONS
*Image via Bing

84. PRINCIPLES WHILE DOING FLUCTUATION
TEST
 ALWAYS PERFORM IN 2 DIRECTIONS AT
RIGHT ANGLES TO EACH OTHER
 TWO FINGERS SHOULD BE KEPT AS FAR
APART AS POSSIBLE
 FREELY MOBILE SWELLINGS SHOULD BE
FIXED FIRST(AS IN HYDROCELE)
 SMALL SWELLINGS –WATCHING FINGER &
DISPLACING FINGER
 VERY LARGE SWELLINGS MORE THAN ONE
FINGFR SHOLD BE USED

85. PSEUDO FLUCTUATION
 A FALSE SENSE OF FLUCTUATION FELT IN
LARGE SOFT SWELLINGS CONTAINING NO
FLUID
 SEEN IN
 LARGE LIPOMA
 MYXOMA
 SOFT FIBROMA
 VASCULAR SARCOMA
 FAIL TO EXPAND IN OTHER PARTS OF A
SWELLING LIKE A TRUE FLUCTUANT
SWELLING

86. CROSS FLUCTUATION
 FLUCTUATION BETWEEN TWO SEPARATE
CYSTIC SWELLINGS COMMUNICATING
WITH EACH OTHER
 SEEN IN
 COMPOUND PALMAR GANGLION
 PSOAS ABSCESS
 PLUNGING RANULA

87. 8.TRANSILLUMINATION
 DEMONSTRATION OF TRANSMISSION OF
LIGHT THROUGH A SWELLING
 POSITIVE IN SWELLINGS CONTAINING
CLEAR FLUID AND THIN TRANSPARENT
WALLS
 NO TRANSILLUMINATION IF WALL IS
THICK, OR TURBID FLUID IS
PRESENT(BLOOD,PUS, LYMPH)
 DARK ROOM , TRANSILLUMINOSCOPE

88. BRILLIANTLY TRANSILLUMINANT SWELLINGS
 1.CYSTIC HYGROMA
 2.EPIDIDYMAL CYST
 3.MENINGOCELE WITH THIN SKIN
 4.RANULA
 5.CONGENITAL HYDROCELE

89. 9.COUGH IMPULSE
 PERFORMED IN SWELLINGS LIKELY TO BE
IN CONTACT WITH ABDOMINAL
,CRANIAL ,SPINAL OR CHEST CAVITY
 SWELLING IS HELD WITH FINGERS AND
PATIENT IS ASKED TO COUGH
 IF THE SWELLING BECOMES TENSE OR
INCREASES IN SIZE IT IS POSITIVE COUGH
IMPULSE
 IN CHILDREN CRYING ACTS AS COUGH

90. SWELLINGS WITH POSITIVE COUGH IMPULSE
 IN CONTINUITY WITH ABD. CAVITY
 HERNIA
 ILIO-PSOAS ABSCSS
 LUMBAR ABSCESS
 IN CONTINUITY WITH PLEURAL CAVITY
 EMPYEMA NECESSITANS
 IN CONTINUITY WITH SPINAL /CRANIAL
CAVITY
 SPINAL/CRANIAL MENINGOCELE

91. 10.REDUCIBILITY
 INDICATION SAME AS FOR COUGH
IMPULSE
 PATIENT IS ASKED TO RELAX
 SWELLING IS COMPRESSED FROM ALL THE
SIDES UNIFORMLY
 REDUCIBLE SWELLINGS DECREASESIN
SIZE OR COMLETELY DISAPPEAR

92. REDUCIBLE SWELLINGS
 1.HERNIA
 2.MENINGOCELE
 3.VARICOCELE
 4.SAPHENA VARIX
 A REDUCIBLE SWELLING ONCE REDUCED
REAPPEARS ONLY BY STRAINING,COUGHING,
OR FORCE OF GRAVITY AS IT INVOLVES
DISPLACEMENT OF VISCERS TO AN ADJOINING
CAVITY

93. 11.COMPRESSIBILITY
 WHEN PRESSURE IS APPLIED TO A
SWELLING IT DECREASES IN SIZE AND
WHEN PRESSURE IS RELEASED SWELLING
REGAINS ITS SIZE ITSELF WITH OUT ANY
EXTERNAL FACTORLIKE STRAINING OR
COUGHING
 CHARECTARISTIC SIGN OF VASCULAR
HAEMANGIOMA

94. 12.PULSATILITY
 WHEN FINGER IS PLACED OVER A
PULSATILE SWELLING IT RAISESWITH
EACH BEAT
 TO TYPES OF PULSATIONS
 TRANSMITTED PULSATIONS- SEEN IN
SWELLINGS PRESENT NEAR AN ARTERY
 EX:CA STOMACH LUMP NEAR ABD.AORTA
 EXPANSILE PULSATIONS-SEEN IN SWELLINGS
ARISING FROM ARTERIES
 EX:AORTIC ANEURYSM

95. HOW TO DIFFERENTIATE?
 TWO FINGERS ARE PLACED OVER THE
SWELLING AND FINGER MOVEMENTS ARE
NOTED
 TRANSMITTED PULSATIONS – FINGERS
ARE SIMPLY LIFTED UP
 EXPANSILE PULSATIONS- FINGERS ARE
LIFTED UP AND MOVE APART

96. IN AN ABDOMINAL LUMP?
 KNEE ELBOW POSITION
 WHEN KEPT IN KNEE ELBOW POSITION
 PULSATIONS DISAPPEAR – TRANSMITTED
PULSATIONS
 PULSATIONS PERSIST –EXPANSILE PULSATIONS

97. 13.FIXITY TO SKIN
 SKIN PINCHED OVER DIFFERENT PARTS OF
THE SWELLING -CANNOT BE PINCHED IF
FIXED TO SKIN
 SKIN IS MADE TO MOVE OVER THE
SWELLING- THE SKIN WILL NOT MOVE IF IT
IS FIXED TO SKIN
 SWELLINGS ARISING FROM SKIN ARE
FIXED TO SKIN EX:SEBACEOUS CYST ,
PAPILLOMA , EPITHELIOMA

98. 14.RELATION TO SURROUNDING STRUCTURES
 1)SUBCUTANEOUS TISSUE
 SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT
ADHERENT TO SKIN OR UNDERLYING MUSCLE
 LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN
SOME PLACES – DUE PRESENCE OF FIBROUS SEPTA
 2)DEEP FASCIA
 SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS
MOBILE AS SUBCUTANEOUS SWELLINGS
 IT IS DIFFICULT MAKE OUT FIXATION TO DEEP FASCIA
AS DEEP FASCIA CANNOT BE MADE TAUT
 EVEN IF TUMOUR IS ATTACHED TO UNDERLYING DEEP
FASCIA &MUSCLE TUMOUR CAN BE MOVED SIDEWAYS

99. 3)RELATION TO MUSCLE
 RELATION SHIP TO MUSCLE IS KNOWN BY
THROWING THE CONCERNED MUSCLE
INTO CONTRACTION
 TUMOURS IN SUB CUTANEOUS TISSUE-
BECOME MORE PROMINENT &REMAIN MOBILE
 TUMOURS ARISING FROM MUSCLE /
INCORPORATED IN MUSCLE-FIXED&IMMOBILE
 TUMORS DEEP TO MUSCLE –LESS PROMINENT,
OR DISAPPEARS,DIFFICULT TO PALPATE

100. 4)SWELLING IN RELATION TO TENDON
 MOVES ALONG WITH TENDON&BECOMES
FIXED WHEN MUSCLE CONTRACTS
 5)IN CONNECTION WITH VESSELS
&NERVES
 DO NOT MOVE ALONG VESSELS OR
NERVES BUT MOVE TO A LITTLE EXTENT
AT RIGHT ANGLES TO THEIR AXES
 6)IN CONNECTION WITH BONE
 IS ABSOLUTELY FIXED IRRESPECTIVE OF
MUSCLE CONTRACTION

101. PERCUSSION
 LIMITED VALUE IN SWELLINGS
 1.TYMPANIC NOTE
 ENTEROCELE
 PHARYNGOCELE
 2.HYDATID THRILL
 HYDATID CYST

102. AUSCULTATION
 BRUIT OVER PULSATILE &VASCULAR
SWELLINGS
 BRUIT
 SHORT,MEDIUM PITCHED MURMUR HEARD
OVER THE SWELLING WITH EACH PULSE WAVE
 EX:ANEURYSM
 THYROTOXIC GOITRE

103. REGIONAL LYMPH NODES
 DRAINING LYMPH NODES EXAMINED IF
INVOLVED NEXT HIGHER GROUP EXAMINED
 IF THE SWELLING ITSELF IS ALYMPH NODE
EXAMINE
 1.OTHER LYMPH NODAL GROUPS
 2.SPLEEN
 3.LIVER
 TO EXCLUDE SYSTEMIC CAUSE
 EXAMINE DRAINAGE AREA TO EXCLUDE INFECTION

104. PRESSURE EFFECTS
 1.OVER BONE – FEEL FOR BONY EROSION
 AS IN DERMOID CYST
 2.IN LIMBS
 DISTAL PULSES- PRESSURE OVER ARTERIES
 EDEMA &DILATED VEINS – PRESSURE OVER
VEINS
 PARESIS& MUSCLE WASTING – PRESSURE
OVER NERVES
 MOVEMENTS OF JOINTS

105. WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE
*Image via Bing

106. SPINAL LIPOMA
*Image via Bing

107. GENERAL EXAMINATION

108. Question time?
 WHAT IS UNIVARSAL TUMOUR?
 WHAT ARE THE PROCESSESS FUSING IN
EXTERNAL ANGULAR DERMOID?
 WHAT IS THE TUMOUR SHOWING
POSITIVE SLIP SIGN?
 WHAT IS THE SITE AT WHICH A LIPOMA
MOST COMMONLY UNDERGOES
SARCOMATOUS CHANGE?
 WHAT IS THE MOST COMMON SITE FOR
CYSTIC HYGROMA?
 WHAT IS THE OTHER NAME FOR BASAL
CELL CARCINOMA?

109. THANKS FOR PATIENT LISTENING
*Image by 40501877@N04 via Flickr