Examination of a lump or a swelling 3.pptx

...

1. Examination of a lump or a swelling

2. 6-10-04 kokomaung 8 History of a Lump  When was it first noticed ? (duration) How did the swelling start? (mode of onset) What are the symptoms related to the lump? ( other symptoms) Has the lump changed size since it was first notice? (progression) secondary changes Exact site Are there any other lumps ? (presence of other lump) There is recurrence after operation or not? There is loss of body weight? loss of appetite history of fever Past history Personal history Family history

3. when was the lump first noticed?(Duration) How long is the lump present there? ( there is a difference between these two questions) remember, first notice the lump 2 months ago is not the same as first appeared 2 months ago painless lump may be present for a long time without patient’s knowledge since birth - congenital swelling e.g. cystic hygroma , meningocele shorter duration & pain - mostly inflammatory longer duration with slight pain – chronic inflammation longer duration and without pain – possibly benign (the longer the duration, the more likelihood of being benign in character) shorter duration – may be malignant growth

4. How did the swelling start?( mode of onset) may appear immediately after trauma – fracture displacement of bone, dislocation of the jaw, haematoma develop spontaneously and grow rapidly with pain – inflammation was noticed causally and gradually increase in size (steadily) – malignant growth very slowly – benign growth swelling appeared in preexisting condition keloid from previous scars (scars of the burn, vaccination, pin prick in the ear, ulcer) malignant melanoma - may develop from a mole or birthmark

5. What are the symptoms related to the lump? (Other symptoms associated with the lump) pain (inflammatory or involving nerves) difficulty in respiration – pressure on trachea difficulty in swallowing – pressure on esophagus interfering with any movement , swelling near joint

6. Pain important and frequent complaint of traumatic and inflammatory swelling Nature of the pain throbbing pain suggests inflammatory lesion leading to suppuration . Pain may be burning, stabbing, aching Site – most often localized to the site of swelling. Referred pain may be present Time of the onset pain before swelling - suggests inflammation swelling before pain - indicates tumours (both benign and malignant) only exception is osteosarcoma in which mild pain is usly 1 st symptom Pain; conspicuously absent in neoplastic swellings particularly in - benign growth and - early carcinoma ( pain appear in carcinoma – complications such as ulceration, fungation deep infiltration, involvement of nerve) .

7. Has the lump changed size since it was first noticed? (Progress of the swelling) growing slowly - Benign growths growing quickly - malignant growths sometimes the swelling suddenly increase in size after remaining stationary for a long period - the malignant transformation of a benign growth swelling decrease in size – purely inflammatory lesion or superimposed inflammatory condition on a malignant growth

8. secondary changes – any change in surface or in consistency softening, ulceration , fungation ,inflammatory changes….... malignant swelling & T.B. lymphadenitis Exact site site of the swelling tells from which organ the swelling was originated. e.g . submandibular region; submandibular gland lymph node plunging ranula .at the fusion of suture lines ; dermoid cyst ( outer canthus of eye)

9. Are there any other lumps? ( presence of other lumps) neurofibromatosis - will always have multiple swelling hodgkin ’ disease – generally shows multiple lymphoglandular enlargements There is recurrence after operation or not if swelling recurs after removal – indicates malignant change in a benign growth or the primary tumour was the malignant one ( dermato sarcoma, parotid adenoma) cystic swelling may recur if the cyst wall is not completely removed

10. There is loss of body weight? associate with loss of body weight – malignant growth or tuberculosis loss of appetite _ malignant & tuberculosis history of fever acute and chronic, inflammatory swellings, malignant swellings, lymphoma

11. Past history similar swelling or recurrent of swelling . tuberculosis may offer clue to the present swelling Personal history smoking and alcoholism are risk features for several malignancies Family history quite important, as many diseases have familial incidence ( tuberculosis, Von Recklinghausen’disease,many malignant tumours ) important in carcinoma breast, medullary carcinoma thyroid

12. Physical examination of the lump A . General examination B. Local examination Inspection Palpation Percussion Auscultation state of regional lymph node

13. General examination when a patient presents with a swelling, the patient should be looked as a whole. massive swelling associated with cachexia are usually indicative of malignant neoplasms . massive inflammatory swellings will produce a toxic effect on the patient. attitude of the patient is also very important. Osteosarcoma ; pressing on the nerve leading to paresis or paralysis of the distal limb displaced fracture or dislocation; abnormal attitude due to that

14. A.Inspection Site Size Shape Surface Colour Edge Number Pulsation skin over the swelling movement with respiration impulse on coughing movement on deglutition movement with protrusion of the tongue any pressure effect

15. 1.Site of the swelling A few swellings are peculiar in their position. Lump may arise from skin, subcutaneous tissue, muscle, tendon, nerve, bone, blood vessels or an organ Dermoid cyst at the fusion of embryonic process ( e.g outer canthus of eye) that means on the line of fusion between the frontal-nasal process and maxillary process. behind the ear ( Post auricular dermoid ) …on the line of fusion of the mesodermal hillocks which form the pinna . Submandibular region; submandibular gland, lymph node plunging ranula S welling at angle of the mandible (may be from hard tissue) : Cyst, Ameloblastoma lump arising from soft tissue ; sarcoma ( masseter muscle)

16. 2.Size measure the exact size in cm. using measuring tape. Measure in longitudinal & vertical dimensions (two dimensions).

17. 3 . Shape of the swelling ovoid, spherical,irregular

18. 4. Surface of the swelling . in certain swelling, surface may be very much obvious and diagnostic . cauliflower surface of squamous cell carcinoma . irregular numerous branched surface of papilloma

19. 5. Colour of the swelling colour of the swelling give a definitive hint to the diagnosis Black colour ; benign nevus and malignant melanoma Red / purple colour ; haemangioma . bluish colour ; ranula , mucous cyst

20. 6.Edge may be clearly defined or indistinct may be pedunculated or sessile

21. 7. Number This is important as this may give a clue to the diagnosis. Some swellings are always multiple ; neurofibromatosis ; diaphysial aclasia ; hodgkins lymphoma ; sebaceous cyst Some swelling are more known to be solitary; lipoma ; dermoid cysts

22. 8.Pulsation Inspect the swelling for any visible pulsations Swelling arising from the arteries are pulsatile e.g aneurysm & vasculargrowth such as carotid body tumour aneurysm of the ascending aorta will bulge through the anterior chest wall ( these give expansile pulsations) S ome swelling over the arteries will be pulsatile ( these will give transmitted pulsations)

23. 9. Skin over the swelling red and edematous ; inflammatory swelling tense, glossary with venous prominance ; sarcoma with rapid growth pigmentation of skin ; mole, naevi ,after repeated exposure to X-ray presence of black punctum over a cutaneous swelling ; sebaceous cyst If scar present ;caused by operation- linear scar with suture marks ;injury- irregular scar ;previous suppuration- (puckered, broad, irregular scar)

24. 10 .Movement with respiration swelling arise from upper abdominal viscera move with respiration (liver ,spleen, stomach,……) 11 . impulse on coughing in case swelling that are likely to be in continuity with the interior of the abdomen, chest, spine,cranium , ask the patient to cough and watch if there is an impulse on coughing 12. movement on deglutition if there is swelling in neck , look for movement with swallow which is specific for thyroid swelling. 13. movement with protrusion of the tongue neck lump; if it move with tongue protrusion- thyroglossal cyst (showing it intimate relationship with thyroglossal tract)

25. 14. any pressure effect artery : diminution of pulse in extreme cases; gangrene vein : cyanosis and oedema (interference with venous or lymphatic return) nerve : paraestesia , anaesthesia , or paralysis neighbouring organ : in head and neck, two structures commonly affected in this way are trachea and oesophagus , with resultant respiratory embrassment and dysphagia

26. B.Palpation palpation is defined as examination with hands. palpation helps to confirm the results of inspection and provide additional information which cannot be obtained by naked eye

27. site, size, shape and, extent surface edge temperature tenderness consistency fluctuation fluid thrill translucency impulse on coughing reducibility compressibility Pulsatility relation to surrounding structures

28. Site, size, shape and, extent visual impression of the sit, size, shape, and extent of the swelling is now corroborate may reveal a much bigger swelling than that estimated by inspection measure the exact size in cm. using measuring tape. Measure in longitudinal & vertical dimensions (two dimensions). fell all around the swelling and estimate its depth is better expressed in terms of inches

29. 2. Surface With the palmer surface of the fingers, palpate the entire surface smooth ; cyst lobular ; papilloma nodular ; a mass of matted lymph nodes irregular and rough ; carcinoma

30. 3. Edge palpate the edge of the swelling all around, since it may not be similar everywhere. ill-defined and merging imperceptibly into the neighboring structure : inflammation and some malignant growth Well- defined; smooth - benign growth ; rough and irregular - malignant growth Margins are palpated by tip of the fingers Well- defined margin ; slip away from the finger - benign tumour such as lipoma is often confusion with a cyst - the benign tumor has a smooth margin, so has a cyst - lipoma ; when pressure upon it slips away from the palpating finger but not yield to it. ( slip sign) cyst ; yields to the palpating fingers and cannot slip away from the examining figure

31. 4. Temperature is best felt by the back of the fingers which is more sensitive than palmer surface. is raised in acute all inflammations and well vascularised tumors (sarcoma)

32. 5.Tenderness (pain on pressure) is a sign which is elicited by clinician on examination Ask the patient to shoe the tender area so that unnecessary discomfort may be avoided When the patient complaint s of pain due to the pressure exerted by the clinician , the swelling is said to be tender Watch the patient’s facial expression instend of repeatedly enquiring about pain. Inflammatory swelling are mostly tender where as neoplastic swelling are not tender unless secondarily infected

33. 6.Consistency Cystic ; cyst and chronic abscess Soft ; lipoma Firm ; fibroma Hard but yielding ; chondroma Stony hard ; malignancy, secondary carcinoma of lymph nodes Bony hard ; osteoma Soft or cystic swelling -suggests fluid in it Solid swelling varies from soft to bony hard Important to palpate all part of the swelling in order to determine whether the consistency is uniform through or variable. i.e some part are cyst, some parts are solid. firm , or hard Variable in consistency ; malignancy

34. While palpating the consistency , one must look for whether the swelling is getting moulded into different shapes or not to pressure. Sign of moulding ; indicate that the content is a pultaceous or putty (sign of indentation) material ( sebaceous cyst or dermoid cyst) Pit on pressure Firm pressure is applied with the finger –when the finger is removed, can see or feel the depression ( most often the swelling is an inflammatory one due to oedematous tissue)

35. 7. Fluctuation Fluctuation is characteristic of cystic swelling i,.e swellings which contain fluid or gas Occasionally absent in tense cysts Both the hands should be used The test should always be performed in two planes at right angle to each other The fingers of each hand must be placed as far as the size of the swelling will allow The finger of one hand will remain steadily pressed against one pole of the swelling. Sharp pressure is now exerted at the opposite pole by the finger of the other hand to displace the fluid. The finger of the first hanh perceive the movement of the fluid and at the same time are passively raised.

36. If the swelling is freely movable : it should be held fixed with the thumb and forefingers of one hand, while the swelling is compressed on the other pole by the thumb and finger of other hand In case of very small swelling , which cannot accommodate two fingers, this test can be performed by simply pressing the swelling at its centre. fluid swelling ; softer at the centre, solid swelling firmer at the centre paget ’ s test Another method- two fingers of left hand on the swelling so as to fix (watching fingers). - right index finger is used (displacing finger) to press on the swelling to displace fluid which is felt by the watching fingers (conventional test- pressure exerted by one finger, will simply displace the swelling, fluctuation test cannot be perform) For very large swelling ; more than one finger of each hand are used False positive ( e,g lipoma – very soft swelling)

37. 8. Fluid thrill in case of swelling containing fluid, a percussion wave is seen to be conducted to its other poles when one pole of it is tapped as done in percussion In case of big swelling ; tapping swelling on one side with two fingers while percussion wave is felt on the other side with palmer aspect of the hand small swelling ; three fingers are placed on the swelling middle finger is tapped with the finger of other hand as done in percussion) the percussion wave is felt by other two fingers on each side

38. 9. Translucency To determine if the fluid inside the swelling is clear or otherwise If the swelling can transmit the light through it ; presence of clear fluid : water,serum,lymph,plasma the wall of the cystic swelling should be transparent Thick & opaque walls or turbid fluids like blood, pus will not allow the light to pass through them

39. 10.impulse on coughing is characteristic of hernia & meningocele in case swelling that are likely to be in continuity with the interior of the abdomen, chest, spine,cranium , ask the patient to cough and watch if there is an impulse on coughing The swelling is grasped and the patient is asked to cough, the impulse is felt by grasping hand due to increase abdominal pressure In case of children ; is performed when they cry

40. 11. Reducibility Swelling reduces and ultimately disappears when it is pressed upon Should be tested in swelling which are likely to be communicating with abdomen, chest, or spinal canal and cranial cavity Ask the patient to relax and compress the swelling uniformly from all sides a reducible swelling will reduce in size & may disappear completely It will reappear only on straining or coughing Reducible swellings Hernias A meningocele varicocele

41. 12. Compressibility It means , the swelling can be compressed, but would not be disappeared completely When the swelling is compressed, it reduces in size & as soon as the pressure is taken off, the swelling regains its original size by itself without any external factors like straining or coughing These swelling are mostly vascular malformations e.g arterial, capillary or venous haemangiomas , lymphangioma

42. 8.Pulsatility Swelling arising from the arteries are pulsatile e.g aneurysm & vasculargrowth such as carotid body tumour , aneurysm of the ascending aorta will bulge through the anterior chest wall ( these give expansile pulsations) S ome swelling over the arteries will be pulsatile ( these will give transmitted pulsations) two fingers, one from each hand are placed on the swelling as far aa possible If two fingers not only raised but also separate dwith each beat of artery ; expansile If two fingers are only raised but not separated ; transmitted

43. 15 . Relation to surroundings structures Skin Subcutaneous tissues Muscle and tendons bones

44. Skin (fixity to overlying skin) The swelling which originate from the skin e.g papilloma , sebaceous cyst ; will be obviously fixed to skin move along with skin unless fix to underlying structure by malignant infiltration ( e.g epithelioma ) If the swelling is deeper to the skin, try to pinch the skin over the swelling at various points or try to move the skin over the swelling with sliding movement If skin can be pinched ; e.g lipoma (it implies that the swelling is not adherent to skin) If the skin is fixed, ; occur in inflammatory condition & carcinoma In malignancy ; tethering of the skin –is the indirect fixity to skin due to direct fixity to the fibrous septa attached to the skin