Download MBBS Important Topics clinical exam of swelling ppt

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Examination of a swelling

* Swelling is defined as Any enlargement or
protuberance in the body due to any cause?

History
1.Particulars of patients
. Chief complaints
. History of presenting illness
. Past history
. Family history
. Personal history
. Drug history
. History of allergy
O N O U1 B W N

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 swellings pain
appears even before the swelling but in case of
tumors swelling 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
swelling. 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

e 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?swellings near
joint
DISFIGURATION

Physical Examination
1. General assessment ? GC
2. Mental status
3. Build and state of nutrition
4. Gait
5. Pallor
6.Cyanosis - central and peripheral
/. 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 swelling- skin/ subcutaneous
tissue/muscle /deep to muscle
Movement with respiration

e 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 swelling cannot be
circular as we do not know about the deeper
dimension of the swelling.
Surface: cauliflower surface of squamous cell
carcinoma ,irregular numerous branched surface of a
papilloma etc. With the palmar surfaces of the fingers,
the clinician should palpate the surface of the swelling
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 generally have smooth
margins whereas malignant growths have
irregular margins. Acute inflammatory swellings
have ill-defined or indistinct margins. The margins
are palpated by the tips of the fingers.
e Consistency:lt may be soft e.g. lipoma; cystic e.g.
cysts and chronic abscesses; firm e.q. fibroma;
hard but yielding e.g. chondroma, bony hard e.qg.
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 swellings arising
from the upper abdominal viscera move with
respiration e.g. those arising from liver, spleen,
stomach, gallbladder, hepatic and splenic flexures of
the transverse colon.
* Impulse on coughing: The swellings, which are in
continuity with the abdominal cavity, the pleural
cavity, the spinal canal or the cranial cavity, will give
rise to impulse on coughing. The patient is asked to
cough and the swelling will 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 swelling.
* It may be due to infection or due to well-
vascularised tumour (e.g. sarcoma). This
examination should be done first in palpation, as
manipulation of the swelling 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

Slip sign : lipoma
Fluctuation
Translucency
Cough impulse
Reducibility
Compressibility
Pulsability
Signs

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.

* Aswelling 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 swelling.
This will increase pressure within the cavity of the
swelling and will be transmitted equally at right angles
to all parts of its wall. If another finger of the other
hand is placed on the opposite pole of the swelling, the
finger will be raised passively due to increased
pressure within the swelling. This means that the
swelling is fluctuating.



* In the first figure it is shown how a small swelling
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 swelling is a solid one. The second
figure is the correct method of eliciting
fluctuation in case of a small swelling. Two fingers
of the left hand (watching fingers ?W?) are placed
on two sides of the swelling and the index finger
of the right hand (displacing finger ?D?) is pressed
on the swelling to displace the fluid within the
swelling

* 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 swellings
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 swelling 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 swelling can be compressed, but would
not be disappeared completely.
The most important differentiating feature between a compressible
swelling and a reducible swelling is that in case of the latter, the
swelling 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

e Auscultation
e 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
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

CACHEXIA ,ANAEMIAAND
LOSS OF WEIGHT
MOBILITY
SURFACE
MARGIN
CONSISTENCY
PRESSURE EFFECT
REGIONAL LYMPH NODE
DISTANT METS
RECURRRENCE
SECONDARY CHANGES
ABSENT
FREELY MOBILE
SMOOTH
DEFINATE AND SMOOTH
FIRM
ABSENT
NOT ENLARGED
ABSENT
NEVER RECURES
NOT SEEN
PRESENT
FIXED EARLY
IRREGULAR
NOT DEFINATE AND
IRREGULAR
HARD OR VARIABLE
CONSISTENCY
PRESENT
OFTEN ENLARGED
MAY BE PRESENT
OFTEN RECURES
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