Examination Of A Swelling

Abdominal swelling (Umbilical hernia)

Swelling:

Any enlargement or protuberance in the body is called swelling. It may be congenital, traumatic, inflammatory, neoplastic or miscellaneous.

Examination:

General Survey:

Patient with swelling should be looked at as a whole. Observe the patient for cachexia or malnutrition and his/her attitude.This general survey is important and may lead to the diagnosis.

Inspection:

Following points should be preciselt noriced:

1- Site: (dermoid cyst commonly seen in midline of the body, pre or post auricular areas)

2- Size: (vertical and horizontal dimensions)

3- Shape: (ovoid, spherical or pear-shaped --- never say circular swelling)

4- Surface: (cauliflower surface in squamous cell carcinoma, irregular numerous branched surface of a papilloma)

5- colour: black(benign nevus, melanoma), red or purple(arterial hemangioma), bluish(ranula)

6- Number: solitary(lipoma, dermoid cyst), multiple(neurofibromatosis, diaphyseal aclasis)

7- Edge: (clearly defined or indistinct, pedunculated or sessile)

8- Pulsation: (vascular swelling)

9- Impulse on coughing: (the swellings which are in continuity with the abdominal, pleural, cranial cavity or spinal canal show positive cough impulse)

10- Peristalsis: (congenital hypertrophic pyloric stenosis)

11- Movement with respiration: (swelling arising from liver, spleen, stomach, gallbladder, hepatic and splenic flexures of colon move with respiration)

12- Movement with deglutition: (thyroid swelling, thyroglossal cysts, subhyoid bursitis, pre or paratracheal lymph node enlagement)

13- Movement with protrusion of tongue: (thyroglossal cyst)

14- Skin over the swelling: red and oedematous(inflammatory), tense glossy with venous prominence(sarcoma), black punctum( sebaceous cyst), pigmentation(moles, naevi), scar(previous operation, injury or suppuration), peau d' orange(CA beast)

15- Any pressure effect: (axillary swelling may cause oedema of upper limb, venous engorgement in neck due to retrostrnal prolongation of swelling.

Palpation:

1- Temperature: (feel the surface of the swelling with the back of fingers and compare with the normal surface on the body) - - - raised temperature(sarcoma- well vascularised tumor)

2- Tenderness: (palpate the swelling keeping an eye on the patient's facial expressions and check for the tenderness) - - - tender(inflammatory swelling), non-tender(neoplastic swelling)

3- Size: (palpate the swelling and have an idea of its deeper dimension)

4- Shape: (ovoid, spherical or pear-shaped --- never say circular swelling)

5- Extent: (palpate and note vertical and horizontal dimensions in cm)

6- Surface: smooth(cystic), lobular with smooth bumps(lipoma), nodular(a mass of matted lymph nodes), rough and irregular(carcinoma)

7- Edge/Margin: Palpate the edge/margin with finger tips. It may be well defined or indistinct--- well defined (neoplastic and chronic inflammatory swelling), ill-defined (acute inflammatory swelling). It may be smooth (benign growth) or irregular (malignant growths). The margin of benign tumor like lipoma does not yield to the palpating finger but slips away from finger whereas margin of cysts yields to the palpating finger and does not slip away.

8- Consistency: The swelling/lump may vary from very soft to very hard. It may be 
      soft (lipoma)
      cystic (cysts or chronic abscesses)
      firm (fibroma)
      hard but yielding (chondroma)
      bony hard (osteoma) or 
      stony hard (carcinoma). 
Bear in mind that consistency of a solid swelling may also be soft as in the case of lipoma. Crepitus may be heard in case of gaseous swelling (gas gangrene, surgical emphysema). Sometimes swelling may be of variable consistency (carcinoma, sarcoma).
During palpation one must assess whether the swelling is getting molded to the pressure applied or not. By this one can assess the content is pultaceous or putty like material. So the swelling must be sebaceous or dermoid cyst or even an abdominal swelling. Swelling may pit on pressure. It means that there is oedematous tissue or the swelling may be inflammatory.

9- Fluctuation: If the pressure applied on one pole of the swelling is felt at the other pole, fluctuation will be positive. Two fingers one, from each hand, are used while performing the test. Pressure is applied on one pole of the swelling with one finger and is felt with other finger placed on the opposite pole. If the fluctuation is positive the finger placed on the opposite pole will raise due to increased pressure inside the swelling. Swelling fluctuates when it contains fluid or gas. The fluctuation test is performed in two planes at right angles to each other and two fingers are placed as far apart as the size of the swelling will allow. More than one fingers can be used for larger swellings.

10- Fluid thrill: The swelling is tapped with two fingers on one side and percussion wave is felt on the opposite side of the swelling with the palm of other hand. Swelling filled with fluid shows positive fluid thrill.

11- Translucency:

12- Impulse on coughing:

13- Reducibility:

14- Compressibility:

15- Pulsatility:

16- Fixity to the overlying skin:

17- Relations to surrounding structures:

18- Plane of the swelling:

Examination of regional nodes, nerves and vessels:

Percussion:

Auscultation:

Measurements:

Movements:

Examination for pressure effects:

 

 Tags: Examination of swelling, inspection, palpation, percussion, auscultation, dermoid cyst, thyroid gland, hernia,