Examination of swelling

Examination of a lump or swelling

1. EXAMINATION OF SWELLING Done by, Dr Anisha S Ashraf 1 st year PG Scholar Department of Shalya Tantra SDM Ayurveda College and Hospital , Hassan

2. INTRODUCTION A lump is a vague mass of body tissue A swelling is a vague term which denotes any enlargement or protruberance in the body due to any cause.

3. HISTORY Duration Mode of onset Symptoms associated with lump Pain Progress of the swelling Exact site Fever Secondary changes Impairment of function Recurrence of the swelling Loss of body weight Past history, personal history, family history

4. HISTORY Duration of Swelling : -How long is the swelling present there? When do you first noticed the swelling? If Congenital Swelling -(Brachial Cyst , Dermoid Cyst , etc ) Swelling with short duration (WITH PAIN)-Mostly Inflammatory Cause Swelling from long duration (WITHOUT PAIN) – Benign Neoplasia Swelling from long duration (WITH PAIN) – Chronic Inflammatory Swelling from short duration (PAINLESS) – Neoplastic/Mostly Malignant.

5. Cont. Mode Of Onset: -How did the Swelling start? May developed just after a Trauma? (Post Extraction Swelling, hematoma,etc ) May developed suddenly and grow rapidly with Severe Pain? (Inflammatory) May noticed casually and gradually increased in size? (Neoplasm) May occur from Pre-existing Conditions.

6. Associated Symptoms Pain is the only symptom which brings the patient to a doctor. In addition to pain we have to ask about, Difficulty In respiration? Ex-Cellulitis Involving Trachea. Difficulty In Swallowing? Ex-Thyroid Goitre,Angioedema

7. Pain It is the most common complaint of traumatic and inflammatory swellings. But pain may be absent in neoplastic (MALIGNANT) swelling. Nature : Throbbing- Inflammation leading to Suppuration. Stabbing/Lancinating- Pain is sudden,Sharp,Severe with Short Duration. Site : Sometimes Pain is referred to some other site than the affected one, (Ex- Pain of Impacted Third Molar leading to Pain in Temporal region.) Time Of Onset : Whether the pain preceeds the swelling? (Inflammatory Swelling) Swelling preceeds the pain? (Benign & Malignant Swellings).

8. Progression of swelling Has the lump changed its size ? Benign growth – very slow growth, sometimes remains static Malignant – grows very quickly Malignant transformation of benign growth – swelling suddenly increases in size If decreases – inflammatory lesion Any change in surface or consistency ?

9. Exact site If Small Swelling- Easy to inspect the exact site. If Swelling is large-Exact site of the swelling can be identified by asking patient to show the exact site from where the swelling has originated at his/her first notice.

10. Recurrence of Swelling : Recurrence even after the removal of cause indicates malignant change in benign growth. Cysts,if not completely enucleated it recurs . Presence of other lumps Neurofibromatosis – multiple swellings Abscess – one after the other

11. Impairment of function Osteosarcoma near knee joint – cause partial or total loss of knee movement. Cold abscess from caries spine – spine movement limitation Loss of body weight Past history Personal history Family history

12. PERSONAL HISTORY Whether the Patient is having an Habit of Betal Nut,Slaked Lime/Tobacco should be asked . Some of the growths in oral cavity are peculiar by the habits which patient is having , like CHUTTA CANCER OF HARD PALATE : Seen commonly in women who smokes cigars with burning ends in the mouth. KHAINI CANCER : Lime addition to tobacco placed in Vestibular sulcus .

13. PHYSICAL EXAMINATION Looked at a whole Cachexia or malnutrition? Attitude of the patient. Raised temperature & pulse rate : inflammatory

14. LOCAL EXAMINATION INSPECTION Situation: Few swellings are peculiar in their positions, Ex- Dermoid Cyst- (Seen at the Midline of the body) Colour : Colour gives a clue for diagnosis Ex- Black- Benign Nevus,Melanoma Red/Purple- Heamangioma . Blue- Ranula

15. Shape: Ovoid/Pear shaped/Spherical/Irregular Never mention as CIRCULAR as we don’t know deeper dimension of swelling,mention it as SPHERICAL . Size : Horizontal and vertical dimensions are noted in centimeters . Surface : Difficult to diagnose by surface but few cases have peculiar surfaces like Cauliflower Surface-Squamous Cell Carcinoma. Filliform Branched Surface (irregular numerous)- Papilloma

16. Edge : Clearly defined or indistinct May be pedunculated or sessile Number : Single/Solitary- Eg -Cyst, Lipoma Multiple- Eg - Tubercular Lymphadenitis, Neurofibromatosis

17. Pulsation Swelling arising from arteries – pulsatile Eg . Aneurysms & vascular growths such as carotid body tumour Which lie just superficial to the artery in close relation with it – transmitted pulsation Those which originate from the arterial walls give rise to expansile pulsation Peristalsis Visible peristalsis in congenital hypertrophic pyloric stenosis Few swellings cause intestinal obstruction & thus shows visible peristalsis.

18. Impulse on coughing : Patient is asked to cough – swelling will give rise to impulse on coughing In children - crying S wellings which are in continuity with abdominal cavity, the pleural cavity, spinal cavity or the cranial cavity

19. Movement on protrusion of tongue Thyroglossal cyst – moves up along with protrusion of tongue Skin over the swelling Red & oedematous – inflammatory swelling Tense, glossy with venous prominence – rapid growth (sarcoma) Black punctum over cutaneous swelling – sebaceous cyst Pigmentation – moles, after repeated exposures to deep X Rays Scar Peau d’ orange – Breast Ca

20. PALPATION Temperature Tenderness Place fingers over the swelling and gently apply pressure , and Observe patient’s Face to know whether swelling is tender or not . Inflammatory swellings mostly tender Size, shape & extent Deeper dimension of swelling

21. Surface Smooth – cyst Lobular with smooth lumps – lipoma Nodular – a mass of matted lymph nodes Irregular & rough – carcinoma

22. Edge, Margin Neoplastic & Chronic Inflammatory Swellings - WELL-DEFINED MARGINS Benign - SMOOTH MARGINS Malignant – IRREGULAR Acute Inflammatory - ILL DEFINED Swellings with well defined margins tend to slip away from the finger SLIP SIGN: Slip sign to differentiate 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,. Then it is a lipoma,if it yields to finger is a cyst

23. Consistency Soft to very hard Soft – lipoma Cystic – cysts & chronic abscesses Firm – fibroma Bony hard – osteoma Stony hard – carcinoma While palpating for consistency, moulding sign must be noted SIGN OF MOULDING OR INDENTATION: 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) Eg-Sebacyous cyst,Dermoid cyst

24. Fluctuation test Fluctuation is POSTIVE if the swelling has liquid or gas. Procedure- By one Finger of each hand Sudden Pressure applied on one border of swelling Pressure with in the swelling increases Transmits pressure to right angles. Another finger is placed on the other border Finger raises slowly by itself due to increased pressure. FLUCTUATION-POSITIVE

25. Paget’s Test If very small swelling, which cannot accommodate two fingers this test can be performed by simply pressing the swelling at its centre . Liquid swelling – softer at the centre than its periphery Solid swelling – firmer at centre than periphery

26. Fluid Thrill In case of a 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 Big swelling – percussion wave is felt on the other side of swelling with palmar apect of hand Small swelling – percussion wave is felt by other two fingers on each side

27. Translucency Transmission of light through a swelling Transillumination - POSITIVE in swellings containing clear fluid and thin transparent walls Transillumination - NEGATIVE if wall is thick, or turbid fluid is present (blood, pus, lymph )

28. Impulse on coughing Swelling is grasped & pt is asked to cough. Impulse is felt by the grasping hand Fixity to skin Skin is pinched over different areas of the swelling Non Pinchable - if fixed to skin Pinchable - Not fixed to skin . Ex: Sebaceous cyst , Papilloma .

29. Reducibility: - I ndication same as for cough impulse , patient is asked to relax. Swelling is compressed from all the sides uniformly Reducible swellings decreases in size or completely disappear . Reducible Swellings , Eg-Meningocele Compressibility : 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 factors like coughing Eg -Characteristic sign of Vascular Haemangioma

30. Relation to surrounding structure Tumours arising from subcutaneous tissue- free from the overlying skin and from the overlying contracted muscle If lipoma pushed sideways, skin will be seen puckering in some places over the tumour

31. REGIONAL LYMPH NODES Regional draining lymph nodes examined If involved next higher group examined If the swelling itself is a lymph node examine Other lymph nodal groups

32. PERCUSSION Presence of gaseous content within the swelling Resonant note over a hernia or to elicit slight tenderness ; eg . Brodie’s abscess Hydatid thrill – special sign in case of a hydatid cyst

33. AUSCULTATION Vascular sounds may be detected. Exclude presence of any bruits/ murmers For example, 'bruit' may be heard over large tumour , vascular goiter and arterial aneurysms Machinery murmer – aneurysmal varix

34. EXAMINATION OF PRESSURE EFFECT Arterial pulse distal to the swelling is felt. Sometimes the swelling may press on the main artery of the limb and causes weak pulse distally Nerves may be affected – causes wasting, paralysis of the muscles May exert pressure on subjacent bone by eroding it; seen in aneurysm and dermoid cyst of skull

35. GENERAL EXAMINATION Haemoptysis / pain in chest? Pulmonary metastasis Liver should be examined Exclude bony metastasis In case of lymph node enlargement, examine other groups of lymph nodes

36. SPECIAL INVESTIGATIONS Blood – TC, DC, Hb %, ESR and sugar Urine RE Aspiration & examination of aspirated material physically, chemically, microscopically & bacteriologically – in case of chronic cystic swellings Fine needle aspiration biopsy or FNAC X RAY Skin test USG CT Scan MRI or Nuclear magnetic resonance Angiography Biopsy

37. DIAGNOSIS Whether the particular swelling is originating from the skin, subcutaneous tissue, muscles, vessel, nerves or bone and secondly the cause of the swelling --- congenital , traumatic, inflammatory, neoplastic, CONGENITAL SWELLINGS Haemangioma Cystic hygroma Meningocele TRAUMATIC SWELLINGS Immediately after a trauma Eg . Haematoma , fracture with displacement, dislocation, rupture of a muscle etc.

38. INFLAMMATORY SWELLINGS --- Acute & Chronic Acute inflammatory swelling Rubor Dolor Calor Tumor Impairment of function Chronic inflammatory Swelling will be more Brawny induration & oedema absent

39. NEOPLASTIC SWELLINGS Benign Grows slowly Encapsulated Move freely Malignant Carcinomas – arise from epithelial cells Sarcomas – origintes from connective tissue Secondary changes like ulceration, degeneration may be present

40. DIFFERENTIAL DIAGNOSIS DERMOID CYST HAEMANGIOMAS TRAUMATIC SWELLINGS INFLAMMATORY SWELLINGS Erysipelas Cellulitis Abscess Boil Carbuncle BENIGN NEOPLASMS Papilloma, Fibroma, Lipoma SEBACEOUS CYST

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