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How to examine a swelling or lump

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Swelling examinations

All the Physical examination including the General and Systemic examinations step by step discussion along with all the possible differential diagnosis.

  1. General examinations
  2. Systemic examinations
  3. Investigations

I. What are the General examination of a swelling or a lump :

  1. Increased body temperature due to any infection or malignancy.
  2. Cachexia or malnutrition
  3. Attitude of the patient – Abnormal attitude may signify swelling like osteosarcoma which presses the nerve ad ultimately leads to paresis of distal limbs.

II. What are the Systemic examination of a swelling or a lump :

I. How to do the Inspection part :

1. Position of the swelling :

Some swellings has unique and specific situation on the body. Like the Dermoid cyst most commonly presents in the midline of the body or on the line of fusion of embryonic processes like at the outer cantos of the eye.

2. Skin over the swelling :

This is the most important factor of infection, because we can diagnose so many diseases by seeing the appearance of the skin.

  1. Red and oedematous – This mainly signifies any Inflammation
  2. Black punctum – Occurrence of this over any cutaneous swelling mainly suggests Sebaceous cyst.
  3. Pigmentation – This mainly signifies Mole
  4. Tense, glossy with venous prominence – This mainly suggests rapid growing Sarcoma
  5. Scars – Linear scar with proper edge and suture marks mainly suggests any surgery in past time, Irregular edges with wound simply suggests any trauma, and Peau d’orange appearance occurs in breast carcinoma.

3. Swelling colour :

During inspection colour of a swelling sometimes gives clues which are specific to some diseases. They can be :

  1. Black colour – This signifies Benign naves and melanoma
  2. Red or purple – This suggests Haemangioma
  3. Bluish colour – This specifies Rannula

4. Number of swellings :

This is one of the most crucial aspects since it provides a clear picture of the reason. Some swellings, such as diaphyseal aclasis, neurofibromatosis, and multiple glandular swellings, are always multiple. Lipoma and dermoid cyst are two examples of isolated swellings.

5. Surface of the swelling :

During inspection it is tough to get the proper idea of the surface about a swelling. But still we can assume that how the surface of a swelling by seeing the tension and texture of the skin.

6. Shape of the swelling :

The shape of most of the swellings remains under spherical types. Other swellings can be ovoid, pear-shaped, kidney-shaped, and irregular shapes.

7. Size of the swelling :

The size of the swelling is another important factor during inspection. In inspection we can only detect the the size in two dimension of that swelling. To get the deeper measurement we need to do the palpation.

8. Boundary of the swelling :

The swelling’s edge can be well defined or vague. It’s possible that the swelling is pedunculated or seessile.

9. Pulsation of the swelling :

Some swellings are pulsatile which arises from the arteries like aneurysm and vascular growths such as carotid body tumour.

On the other hand some swellings seems to be pulsatile which lies superficial to the artery.

10. Swellings associated with peristalsis :

  • Some swellings, such as congenital hypertrophic pyloric stenosis, are linked to visible peristalsis.
  • Some swellings impede the intestine, resulting in apparent peristalsis.

11. Movement of the swelling with respiration :

Certain swellings in the upper abdomen viscera shift in response to breathing.

Examples, those arising from :

  • Liver
  • Stomach
  • Spleen
  • Gallbladder
  • Hepatic and splenic flexures of the transverse colon

12. Coughing Impulse :

The patient is urged to cough, and when coughing, the swelling will be seen, causing an impulse. Coughing will work in the case of crying children.

The swellings are in the continuation with the :

  • Pleural cavity
  • Abdominal cavity
  • Cranial cavity

13. Movement of the swelling during deglutition :

During deglutition, a few swellings attached to the larynx or trachea migrate.

Examples are swellings fixed with :

  • Pre or paratracheal lymph node enlargement
  • Subhyoid bursitis
  • Thyroid swelling
  • Thyroglossal cyst

14. Movement of the swelling with protrusion of the tongue :

A thyroglossal cyst travels up with tongue protrusion, demonstrating its close relationship to the thyroglossal tract.

15. Other diagnosis :

  • An axillary swelling with oedema in the upper limb indicates that the swelling is most likely caused by a lymph node.
  • Wasting of the distal limb – This usually signifies a traumatic swelling, and the wasting is caused by either non-use of the upper limb or nerve injury.
  • Swelling in the neck with venous engorgement – This usually means there’s a chance the swelling will extend retro-sternally, causing venous blockage.

II. How to do the Palpation part :

The most significant element of the local examination is palpation, which will not only confirm the findings of the inspection, but will also investigate certain other findings that will provide a definitive hint to the diagnosis.

1. Temperature of the swelling :

The back of the hand is used to feel the temperature of any swelling. There are various causes of increased temperature :

  • Inflammation due to any infection.
  • Increased excessive vascularity.
  • Well-vascularised tumour like Sarcoma.

2. Tenderness of the swelling :

Inflammation can create tender swellings, while neoplasia can cause non-tender swellings. The swelling is described as ‘sensitive’ when the patient complains of pain as a result of the clinician’s pressure. To evoke tenderness, be careful and avoid inflicting too much pain on the sufferer.

3. Size, shape and Extent of the swelling :

  • The examiner can get a sense of the swelling’s deeper dimensions, which are unknown during the inspection, by palpating it.
  • The clinician should make every effort to determine the full amount of the swelling. If a section of the swelling hides behind a bone, this should be noted, and the importance of this cannot be overstated to the pupils.

4. Surface of the swelling :

The surface of the swelling is palpated using the palmar surfaces of the fingers, and the physician should palpate the swelling completely.

There can be various appearance of the surface of a swelling, and they are :

  • Lobular with smooth bumps which suggests Lipoma
  • Nodular swelling which indicates lymph node
  • Smooth which implies cyst
  • Irregular or rough surface which indicates carcinoma

5. Boundary or margin of the swelling :

The boundary of the swelling is palpated very preciously. We can get various boundary or margin of the swelling, by which we also can categorise the disease.

  1. Smooth margins – Mainly suggests Benign growth
  2. Well-defined margins – Neoplastic swellings and chronic inflammatory swellings
  3. Ill-defined margins – This mainly suggests Acute inflammatory swellings
  4. Irregular margins – This mainly indicates Malignant tumour

6. Attaching or fixing property with the overlying skin :

The swelling that arises from the skin will be permanently attached to the skin. Unless malignant infiltraton fixes them to underlying structures, they will always migrate with the skin.

There are mainly two types of tests, and they are :

  1. The skin is made to move over the swelling, but if it is not attached to the skin, it will not move.
  2. When the skin around the edoema is not fixed, it is squeezed up in various places.

7. Relations of the swelling to surrounding structures :

Based on the types and origin of the tumour, we can divide this into six types :

  1. Subcutaneous tissue – Tumours developing from this tissue are visible without the covering skin or the constricted muscle beneath.
  2. The deep fascia – This tumours will be less migratory than those that arise from subcutaneous tissue.
  3. Muscles – Muscle-derived tumours can be moved while the muscle is relaxed.
  4. Deep tendon – When the muscle is stretched taut against opposition, these swellings travel along with the tendon and become permanent.
  5. The vessels and nerves – This do not move in the same direction as the vessel or nerve, but rather at a little angle to their axis.
  6. Bone – Even when the overlaying muscle is completely relaxed and cannot be pulled away from the bone, the swellings remain completely set.

8. Consistency of the swelling :

Consistency of a swellings can be Uniform and variable.

Uniform consistency : This can be of various types

  1. Soft feeling – Mainly suggests lipoma
  2. Cystic – Due to any cyst like dermoid cyst, chronic abscess
  3. Firm feeling – This mainly occurs due to Fibroma
  4. Hard feeling – This is due to Chondroma
  5. Bony hard – Mainly suggests Osteoma
  6. Gaseous swelling – This can be due to gas gangrene, surgical emphysema etc.

Variable consistency : This mainly suggests any Malignancy

9. Fluctuation property of the swelling :

If a swelling contains any fluid or gas then it may show fluctuation property.

  • On one pole of the bulge, sudden pressure is applied. This will increase pressure within the swelling’s cavity, which will be transmitted at right angles to all areas of the swelling’s wall.
  • If a finger from the opposite hand is placed on the opposite pole of the swelling, the finger will passively elevate due to increasing pressure within the swelling.

10. Percussion wave shown by the swelling :

When one pole of a bulge carrying fluid is tapped as in percussion, a percussion wave is seen to be propagated to the other poles.

There may be two types of selling – Big swelling and Small swelling.

  1. Big swelling – This can be illustrated by tapping the swelling with two fingers on one side while feeling the percusion wave with the palmar aspect of the hand on the other side.
  2. Small swellings – The percussion wave is felt by the other two fingers on each side after three fingers are put on the swelling and the middle finger is tapped with a finger from the other hand.

11. Translucency property shown by the swelling :

  • This means that light can pass through the swelling. It must contain transparent fluid, such as water, serum, lymph, plasma, or highly refractile fat, to do this.
  • A pultaceous substance, such as a dermoid or sebaceous cyst, that has swelled.

12. Pulsatility shown by the swelling :

We can pulsate a swelling if it follows any criteria :

  • When it arises from artery
  • When it lies very close in surrounding of an artery
  • When the swelling is very easy to identify

13. Impulse on coughing :

This test confirms the findings discovered during inspection by palpation. The swellings that are most likely to cause an urge when coughing are:

  • Hernia, ilio-psoas, and lumbar abscess are examples of those that are connected to the abdominal cavity.
  • Those that extend into the pleural cavity, such as emphyema necessitatis.
  • Those that run parallel to the spinal canal or the cranial cavity.

14. Reducibility of the swelling :

This property mainly suggests that the swelling gets disappears or reduces while pressure is given. This occurs in :

  • Hernia
  • Lymph nodes
  • Varicocele
  • Saphena varix
  • Meningocoele
  • Varix

15. Compressibility of the swelling :

Compressibility suggests that the edoema can be compressed but not totally removed. There may be no connections between the compressible swelings and the abdominal, pleural, or cerebral cavities.

III. How to do the Percussion part :

This is done to eliminate the two probable chance that, if the swelling is containing any gases like in resonant note over a hernia, and slight tenderness like in Brodie’s abscess.

IV. How to do the Auscultation part :

Auscultation of all pulsatile swellings should be performed to rule out the existence of any bruits or murmurs. An aneurysmal varix produces a machinery murmur.

V. How to do the Measurements :

If any muscle wasting is present then it should be measured.

VI. How to check the Movements :

Near by joint is examined followed by the situation of the swelling. If the swelling is present at the neck, then we can examine the shoulder joint cervical spine etc.

To read about the joint movements click on the links given below :

III. What are the Investigations to be done of a swelling or a lump :

  1. Blood test – We can check total count, differential count, E.S.R and haemoglobin estimation.
  2. Skin test
  3. Urine analysis – Sugar test is done.
  4. Aspiration and clinical examination of that material.
  5. FNAC – This technique is done for Exfoliative cytology.
  6. X-Ray – Simple X-Ray is done to check any bony swelling.
  7. USG
  8. CT Scan
  9. 3D CT
  10. MRI

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