Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Examination of a Swelling Notes Handwritten Notes
Examination of a swelling
? Swelling is defined as Any enlargement or
protuberance in the body due to any cause"
History
1.Particulars of patients
2. Chief complaints
3. History of presenting illness
4. Past history
5. Family history
6. Personal history
7. Drug history
8. History of allergy
Particulars of patient
1. NAME
2. AGE
3. SEX
4. RELIGION
5. OCCUPATION
6. SOCIAL STATUS
7. Address
History of presenting illness
Begins with the first symptom and extend to the
time of examination. Includes
? 1. Mode of onset
? 2. Progression
. 3. Duration
Questions could be asked as
When and how was the swelling noticed
How did it progress in size and appearance
Swelling history
? Site
? Size
? Number
? Duration
? Mode of Onset
? progress
? Pain and duration
? History of trauma
? Fever
? Associated Symptoms
? Secondary Changes
? Impairment of Function
? Loss of weight
? Recurrence
? Past history: Tuberculosis, malignancy
? Personal History: alcoholic or smoker
? Family History: important in ca breast or ca
thyroid
? LONGER DURATION WITH OUT PAIN:BENIGN
? SINCE BIRTH:CONGENITAL
? SHORT DURATION & PAIN: INFLAMMATORY
? LONGER DURATION WITH PAIN AND SHORT
DURATION-MAYBE MALIGNANT
PAIN
? Time of onset: in inflammatory swel ings pain
appears even before the swel ing but in case of
tumors swel ing appears long before pain.
? In malignant conditions pain is due to
involvement of nerves, fungation,ulceration,deep
infiltration, which indicates inoperability
? Site: most often pain is localized to the site of
swel ing. referred pain may be present.
? Nature of pain: throbbing pain suggests
inflammation leading to suppuration.
PROGRESS
? DECREASING IN SIZE-inflammatory swellings
? SUDDENLY INCREASING IN SIZE AFTER
REMAINING STATIONERY FOR SOME TIME-
malignant transformation of benign swellings
? GROWING QUICKLY-malignant swelling
? GROWING SLOWLY-benign swellings
? Other symptoms associated with it
? difficulty in swallowing and respiration
? Pain- site /onset /character/radiation/
aggravating and relieving factors
? Secondary changes ?ulceration ,fungation and
pigmentation
? History of fever ? may be present in
lymphoma , inflammatory swelling and
malignant swellings
? Family history is important in tuberculosis
? PAIN----inflammatory or involving nerves
? DIFFICULTY IN RESPIRATION---pressure on
trachea
? DIFFICULTY IN SWALLOWING---pressure on
esophagus
? INTERFFERING WITH MOVEMENT--swel ings near
joint
? DISFIGURATION
Physical Examination
? 1. General assessment ? GC
? 2. Mental status
? 3. Build and state of nutrition
? 4. Gait
? 5. Pal or
? 6.Cyanosis - central and peripheral
? 7. Icterus
? 8. Edema
? 9. Temperature
Local Examination of swelling
? A. Inspection
? B. Palpation
? C. Percussion
? D. Auscultation
? E. Examination of
pressure effect
Inspection
? 1. Site/ location- Idea about its origin
? 2. Color ?Black, Red/purple, Bluish
? 3. Shape- oval/ globular / spherical
diffuse /loacalised
? 4. Size- tense / erythematous/ pigmentation
? 5. Number ? solitary , multiple
? 6.Edges /margins
? 7. Pulsation
? 8. Movement on deglutition
? 9. Movement with protrusion of tongue
? 10. Skin over swelling ? Red & edematous,
tense and glossy, peau-d-orange
? 11. Surrounding area
Palpation
? Site
? number
? Size
? shape
? extent
? Temperature
? Tenderness
? Surface-smooth/nodular/lobular/irregular
? Skin
? Edges ?Variable/Uniform
? Consistency-soft/cystic/firm/hard
? Fluctuation
? Translucency
? Reducibility
? Fixity to overlying skin
? Relation to surrounding structures
? Plane of swel ing- skin/ subcutaneous
tissue/muscle /deep to muscle
? Movement with respiration
? site: A few swellings are peculiar in their
positions such as dermoid cysts are mostly
seen in the midline of the body or on the line
of fusion of embryonic processes e.g. at the
outer canthus of the eye
? Colour: Black colour of benign naevus and
melanoma, red or purple colour of
haemangioma, bluish colour of ranula are
obvious and diagnostic.
? Shape: whether it is ovoid, pear-shaped, kidney-
shaped, spherical or irregular. A swel ing cannot be
circular as we do not know about the deeper
dimension of the swel ing.
? Surface: cauliflower surface of squamous cel
carcinoma ,irregular numerous branched surface of a
papil oma etc. With the palmar surfaces of the fingers,
the clinician should palpate the surface of the swel ing
which may be smooth (cyst), lobular with smooth
bumps (lipoma), nodular (a mass of matted lymph
nodes) or irregular and rough(carcinoma).
? Edges: Benign growths general y have smooth
margins whereas malignant growths have
irregular margins. Acute inflammatory swel ings
have il -defined or indistinct margins. The margins
are palpated by the tips of the fingers.
? Consistency:It may be soft e.g. lipoma; cystic e.g.
cysts and chronic abscesses; firm e.g. fibroma;
hard but yielding e.g. chondroma, bony hard e.g.
osteoma or stony hard e.g. carcinoma.
? The swellings, arising from the arteries, are
pulsatile, e.g. aneurysms and vascular
growths, such as carotid body tumour. The
swellings, which lie just superficial to the
artery in close relation with it, will be pulsatile.
This pulsation is called transmitted pulsation,
whereas those which originate from the
arterial walls give rise to expansile pulsation.
? Movement with respiration: Certain swel ings arising
from the upper abdominal viscera move with
respiration e.g. those arising from liver, spleen,
stomach, gal bladder, hepatic and splenic flexures of
the transverse colon.
? Impulse on coughing: The swel ings, which are in
continuity with the abdominal cavity, the pleural
cavity, the spinal canal or the cranial cavity, wil give
rise to impulse on coughing. The patient is asked to
cough and the swel ing wil be seen giving rise to an
impulse while the patient is coughing.
? A few swellings which are fixed to the larynx
or trachea move during deglutition e.g.
thyroid swellings, thyroglossal cysts, subhyoid
bursitis and pre-or paratracheal lymph node
enlargement.
Temperature
? Local temperature is raised due to excessive
vascularity of the swel ing.
? It may be due to infection or due to wel -
vascularised tumour (e.g. sarcoma). This
examination should be done first in palpation, as
manipulation of the swel ing during subsequent
examinations may increase the temperature
without any definite reason. Temperature of the
swelling is best felt by the back of the fingers.
Plane of swelling
? Skin
? Subcutaneous tissue-free from skin and
muscle both. skin is pinchable. Freely mobile.
prominent when muscle is contracted
? Deep fascia: not as mobile ,difficult to
distinguish if arising from subcutaneous tissue
? Fixed to muscle: more prominent on muscle
contraction but not as mobile.
Deep to muscle : disappears
Bone: fixed
Signs
? Slip sign : lipoma
? Fluctuation
? Translucency
? Cough impulse
? Reducibility
? Compressibility
? Pulsability
Slip sign
? Slip sign.-- When the edge of a swelling is
palpated, the margin of the solid swelling does
not yield to the palpating finger but slips away
from it; but in case of a cystic swelling the
edge yields to the pressure of the palpating
finger and does not slip away.
? A swel ing fluctuates, when it contains liquid or gas.
? This test should be carried out by one finger of each
hand.
? Sudden pressure is applied on one pole of the swel ing.
This wil increase pressure within the cavity of the
swel ing and wil be transmitted equal y at right angles
to al parts of its wal . If another finger of the other
hand is placed on the opposite pole of the swel ing, the
finger wil be raised passively due to increased
pressure within the swel ing. This means that the
swel ing is fluctuating.
? In the first figure it is shown how a smal swel ing
may be displaced as a whole by the displacing
finger (D) and it shifts towards the watching
finger (W) to elicit a false sense of fluctuation
even when the swel ing is a solid one. The second
figure is the correct method of eliciting
fluctuation in case of a smal swel ing. Two fingers
of the left hand (watching fingers `W') are placed
on two sides of the swel ing and the index finger
of the right hand (displacing finger `D') is pressed
on the swel ing to displace the fluid within the
swel ing
? For very large swelling more than one finger of
each hand are used. Two or even three fingers
may be used for providing pressure (displacing
fingers) and palmar aspect of four fingers of the
other hand may be used to perceive the
movement of displaced fluid (watching fingers)
? Very soft swellings sometimes yield false
positive sense in fluctuation test. The swel ings
which can be included in this list are : lipoma,
myxoma, soft fibroma, vascular sarcoma etc.
? Translucency.-- This means that the swelling can transmit
light through it. For this, it must contain clear fluid, e.g.
water, serum, lymph, plasma or highly refractile fat.
? A swelling may be fluctuant as it contains fluid, but may not
be translucent when it contains opaque fluid, such as blood
or pultaceous material (dermoid or sebaceous cyst).
? To carry out this test, darkness is essential. In day time, this
can be achieved by a roll of paper, which is held on one side
of the swelling, while a torch light is held on the other side
of the swelling. The swelling will be seen to transmit the
light, if it is a translucent swelling.
? Reducibility.-- This means that the swel ing reduces and ultimately
disappears when it is pressed upon. This is a feature of hernia.
Lymph, varix, varicocele, saphena varix, meningocele etc. are also
reducible partly or completely.
? Compressibility means the swel ing can be compressed, but would
not be disappeared completely.
? The most important differentiating feature between a compressible
swel ing and a reducible swel ing is that in case of the latter, the
swel ing completely disappears as the contents are displaced into
the cavities from where they have come out and may not come
back until and unless an opposite force, such as coughing or gravity
is applied.
? Two fingers, one from each hand, are placed on the
swelling as far apart as possible . If the two fingers are
raised with each throb of the artery, the swelling is a
pulsatile one. When the two fingers are not only raised,
but also separated with each beat of the artery, the
pulsation is said to be an `expansile' one.
? When the two fingers are only raised, but not separated,
the pulsation is said to be `transmitted'.
? In case of pulsatile swelling of the abdomen, the patient is
placed in the knee-elbow position to determine whether it
is an aneurysm of the abdominal aorta or a tumour lying in
front of the abdominal aorta (transmitted pulsation). In
case of the latter in this position pulsation ceases.
? Lymph node examination
Percussion
? To find out gaseous content of the swelling.
? Eg: resonant note in hernia.
? Hydatid thrill- 3 fingers test
? Auscultation
? All pulsatile swelling should be auscultated to
hear any bruits
Examination of pressure effect
? 1. Artery ?weak distal pulse
? 2. Nerve-muscle wasting
? 3. Bone-erosion
Investigations
? ESR ? elevated in inflamatory swellings,
malignancy, anaemia
? In case of recurrent abscess RBS is important
along with urine routine and microscopy
? Aspiration of material (diagnostic/
therapeutic)
? FNAC
? Xray ?in bony swellings to rule out bone
erosions
? Ultrasonography-non invasive, non expensive ,
can comment on solid and cystic nature of
swelling
? CT Scan
? MRI
? BIOPSY-(Needle /punch /Open biopsy)
? Open biopsy ? excisional and incisional biopsy
? Incisional biopsy can cause spread of tumour
Difference between benign and
malignant swelling
SYMPTOM
BENIGN
MALIGNANT
DURATION
SLOW GROWTH
RAPID GOWTH
AGE
YOUNGER AGE
>40
PAIN
USUALLY ABSENT
MAY BE PAINFUL
LOSS OF WEIGHT
NEVER SEEN
PRESENT
LOSS OF FUNCTION
NOT SEEN
SEEN QUITE EARLY
BENIGN
MALIGNANT
CACHEXIA ,ANAEMIAAND
ABSENT
PRESENT
LOSS OF WEIGHT
MOBILITY
FREELY MOBILE
FIXED EARLY
SURFACE
SMOOTH
IRREGULAR
MARGIN
DEFINATE AND SMOOTH
NOT DEFINATE AND
IRREGULAR
CONSISTENCY
FIRM
HARD OR VARIABLE
CONSISTENCY
PRESSURE EFFECT
ABSENT
PRESENT
REGIONAL LYMPH NODE
NOT ENLARGED
OFTEN ENLARGED
DISTANT METS
ABSENT
MAY BE PRESENT
RECURRRENCE
NEVER RECURES
OFTEN RECURES
SECONDARY CHANGES
NOT SEEN
OFTEN PESENT
Danger signs
? Sudden increase in size
? Increased vascularity with local rise of
temperture
? Fixity to surrounding structures
? Secondary changes ?pigmentation /ulceration
and bleeding
? Pain
? Enlarges regional lymph nodes
This post was last modified on 11 August 2021