Examination of the swelling

ByDr.K.Priyatham

General considerations• You should wash your hand in the presence of

the patient before beginning the physical examination

• A new patient warrants a complete examination, regardless of chief complaint

• The sequence of comprehensive examination should maximize the patient’s comfort

• As a beginner, you should avoid interpreting your findings for the patient

PATIENT’S PROBLEM

HOW TO SOLVE IT?

HISTORY CLINICAL EXAMINATION CLINICAL DIAGNOSIS (dif-dx) INVESTIGATIONS FINAL DIAGNOSIS TREATMENT

What are the five important points, you have to do, before examination-taking?????

IMPORTANT POINTS BEFORE EXAMINATION-TAKING Introduce yourself Explain yourself Take patient permission to do the examination Ideal exposure Define the Position of both

Treat with respect

CLINICAL EXAMINATION Observe while history taking

• General health• Intelligence• Attitude• Mental state• Posture/ Mobility

Ask for a nurse when examining females Patient’s permission

The comprehensive physical examination; first impressions

• General survey: general state of health; height, weight, build, sexual development, motor activity, facial expression, state of awareness or level of consciousness.

• Vital signs: blood pressure, pulse number and respiratory rate.

• Skin: color, lesions. Inspection and palpation of hair and nails.

CLINICAL EXAMINATION

Four basic techniques:• Inspection• Palpation• Percussion• Auscultation

INSPECTION• 1. SITE- EXACT ANATOMICAL LOCATION

IMPORTANT AS SOME SWELLINGS OCCUR IN A TYPICAL POSITION WHICH IS DIAGNOSTIC

• EXAMPLES– POST AURICULAR DERMOID-BEHIND EAR– EXTERNAL ANGULAR DERMOID –LATERAL

END OF EYE BROW– MENINGOCELE- OVER THE BACK IN MIDLINE

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EXTERNAL ANGULAR DERMOID

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EXTERNAL ANGULAR DERMOID

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POST AURICULAR DERMOID

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SUB MANDIBULAR DERMOID

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DERMOID CYST OF SCALP

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DERMOID CYST IN MID LINE

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ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW

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MENINGOCELE

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MENINGOCELE

2.NUMBER• USUALLY SINGLE , SOME TIMES

MULTIPLE• MULTIPLE EXAMPLES

– MULTIPLE NEUROFIBROMATOSIS(VON RECK LING HAUSENS DISEASE)

– MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)

– DIAPHYSEAL ACLASIS– HYDRADENITIS SUPPURATIVA– MULTIPLE LYMPHOGLANDULAR

SWELLINGS

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MULTIPLE LIPAMATOSIS

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HYDREDENITIS SUPPURATIVA OF AXILLA

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3.SHAPE• SPHERICAL

• OVOID

• KIDNEY /BEAN SHAPED/RENIFORM

• IRREGULAR

4.SIZE EXACT SIZE USING A MEASURING TAPE

LONGITUDINAL & TRANSVERSE ON INSPECTION

DEPTH BETTER JUDJED ON PALPATION

• USUALLY NOTED IN CENTIMETRES

5.SURFACE• COLOUR

• SPECIAL CHARACTER OF SURFACE

• OVERLYING SKIN

A)COLOUR• ARTERIAL HAEMANGIOMA – BRIGHT RED

• VENOUS HAEMANGIOMA— PURPLE

• MALIGNANT MELANOMA- BLACK

• BENIGN NAEVUS – BLACK

• RANULA –BLUE

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CAPILLARY HAEMANGIOMA OVER FORE HEAD

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BENIGN NEVUS

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HERIDITARY DYSPLASTIC NAEVUS SYNDROME

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MALIGNANT MELANOMA

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MALIGNANT MELANOMA OF FOOT

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RANULA

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RANULA OF RIGHT SUBLINGUAL

b)Character of surface• TWO CHARACTERISTIC SURFACES ON

INSPECTION– CAULIFLOWER SURFACE – SQUAMOUS

CELL CARCINOMA– FILIFORM BRANCHED SURFACE –

PAPILLOMA (IRREGULAR NUMEROUS BRANCHED SURFACE)

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SQUAMOUS CELL CARCINOMA

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SCC OF TONGUE

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FILIFORM SURFACE OF PAPILLOMA

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INDONESIAN TREE MAN

H.P.V. AFFECTING HANDS &LEGS

c)Skin over lying swelling • TENSE , SHINY WITH PROMINENT VEINS – SARCOMA• RED &EDEMATOUS – INFLAMMATORY• BLACK PUNCTUM – SEBACEOUS CYST• PIGMENTATION-MOLES , NAEVI OR REPEATED X-

RAYS• SCAR

– PREVIOUS OPERATION(REGULAR SCAR WITH SUTURE MARKS)

– INJURY(REGULAR SCAR)– SUPPURATION(PUCKERED ,BROAD &IRREGULAR) – PEAU - D ORANGE APPEARANCE(MAINLY IN CA. BREAST)

• ULCERS

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ABSCESS

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ABDOMINAL WALL ABSCESS

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NASAL ABSCESS

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INFECTED SEBACEOUS CYST WITH PUNCTUM

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SOFT TISSUE SARCOMA

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POST THYROIDECTOMY SURGICAL SCAR

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6.VISIBLE PULSATIONS• PULSATION

– A MOVEMENT OR INCREASE IN SIZE SYNCHRONOUS WITH EACH HEART BEAT

– 2 TYPES• EXPANSILE PULSATIONS – SWELLINGS

ARISING FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID BODY TUMOUR

• TRANSIMITTED PULSATIONS – SWELLINGS CLOSE TO ARTERIES

• REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION

7.VISIBLE COUGH IMPULSE PERFORMED WHEN SWELLING IS OVER

ABDOMEN,CHEST,SPINAL CANAL OR CRANIUM COUGH IMPULSE

VISIBLE INCREASE IN THE SIZE OF SWELLING SYNCHRONOUS WITH COUGH

POSITIVE IN SWELLINGS COMMUNICATING WITH ABDOMEN,THORACIC CAVITY,SPINAL CANAL OR CRANIAL CAVITY

POSITIVE COUGH IMPULSE

• HERNIA

• MENINGOCELE

• VARICOCELE

• SAPHENA VARIX– IN CHILDREN CRYING ACTS AS

COUGHING

8.VISIBLE PERISTALSIS• OBSERVED IN ABDOMINAL LUMPS

AND INGUINAL SWELLINGS• CONGENITAL HYPERTROPHIC

PYLORIC STENOSIS – VISIBLE GASTRIC PERISTALYSIS

• INGUINAL HERNIAS (ENTEROCELE) INTESTINAL PERISTALYSIS

• LUMPS DUE TO INTESTINAL MALIGNANCY PERISTALYSIS IS SEEN

9.MOVEMENT WITH RESPIRATION

SEEN IN ABDOMINAL LUMPS SWELLINGS ARISING FROM

STOMACH LIVER SPLEEN GALLBLADDER HEPATIC FLEXURE OF COLON SPLENIC FLEXURE OF COLON RENAL LUMP THOUGH NOT IN CONTACT WITH

DIAPHRAGM ,MOVES WITH RESPIRATION

10.Movement with deglutition• IN CASE OF NECK SWELLINGS

– SWELLINGS MOVING WITH DEGLUTITION• THYROID SWELLING• THYROGLOSSAL CYST• THYROGLOSSAL FISTULA• SUBHYOID BURSA• PRE/PARA TRACHEAL LYMPH NODES• EXTRINSIC CARCINOMA OF LARYNX

WHY THYROID MOVES UP WITH DEGLUTITION?

• THYROID IS ENCLOSED IN PRETRACHEAL FASCIA

• PTF ATTACHES TO THYROID &CRICOID CARTILAGES(BERRY’S LIGAMENT)

• SUPERIOR CONSTRICTOR MUSCLE CONTRACTION DURING DEGLUTITION

• THESE CARTILAGES MOVE UP• ALONG WITH THESE THYROID MOVES

UP

11)MOVEMENT WITH TONGUE PROTRUSION

• IN CASE OF MID LINE NECK SWELLINGS

• EG:THYROGLOSSAL CYST &FISTULA

• WHY?

– ATTACHED TO FORAMEN CAECUM OF TONGUE

12)PRESSURE EFFECTS• WHEN SWELLING IS PRESENT ON

LIMBS – AN AXILLARY SWELLING WITH LIMB

EDEMA – LYMPHNODAL SWELLING– PARESIS – PRESSURE ON NERVES– WASTING OF MUSCLES OF DISTAL LIMB-

TRAUMATIC SWELLING(WASTING DUE TO NON-USE/INJURY TO NERVES)

– SWELLING IN NECK WITH VENOUS ENGORGEMENT(RETROSTERNAL EXTENSION)

PALPATION• DEFINITE CLUE TO DIAGNOSIS

• METHODICAL,FOLLOW DEFINITE ORDER

• BE GENTLE

• SHOULD NOT HURT THE PT.

1.TEMPERATURE• IT IS AN ABSOLUTE STANDARD

PRACTICE TO TEST FOR TEMP FIRST-WHY?

• BEST FELT BY BACK OF THE HAND-WHY?

• INCREASED IN– INFLAMMATORY SWELLING– WELL VASCULARISED TUMOURS-

SARCOMA

2.TENDERNESS• PAIN DUE TO PRESSURE EXERTED

OVER THE SWELLING IS TENDERNESS• PALPATE GENTLY OVER ALL THE

AREA• IT IS A SIGN• FEATURE OF

– INFLAMMATORY SWELLINGS– SWELLING RELATED TO NERVES -

NEUROFIBROMA

3.SIZE& SHAPE• CONFIRM VERTICAL & HORIZONTAL

DIMENSIONS

• NOTE THE THIRD DIMENSION DEPTH WHICH COULD NOT BE EXACTLY DETERMINED BY INSPECTION

4.SURFACE• WITH PALMAR SURFACE

– SMOOTH –CYSTIC SWELLINGS– LOBULARWITH SMOOTH BUMPS-LIPOMA– NODULAR –MULTI NODULAR

GOITRE/MATTED LYMPH NODES– IRREGULAR - CARCINOMA

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SMOOTH SURFACE OF A SEBACEOUS CYST

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M..N.G. WITH NODULAR SURFACE

5.EDGE• 1)WELL DEFINED & REGULAR –

BENIGN NEOPLASMS

• 2)WELL DEFINED & IRREGULAR –MALIGNANT NEOPLASM

• 3)ILLDEFINED &DIFFUSE –INFLAMMATORY SWELLINGS

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ABSCESS WITH ILL DEFINED MARGINS

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LIPOMA WOTH WELL DEFINED MARGINS

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LARGE LIPOMA WITH WELL DEFINED MARGINS

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IRREGULAR BORDERS IN CARCINOMA BREAST

SLIP SIGN

• TO DEFFERENTIATE 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,. DOES NOT YIELD TO IT , IT IS A LIPOMA,IF IT YIELDS TO FINGER IS A CYST

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6.CONSISTENCY• SOFT – LIPOMA• CYSTIC- CYSTS &CHRONIC

ABSCESSES• FIRM –FIBROMA• HARD BUT YIELDING-CHONDROMA• BONY HARD-OSTEOMA• STONY HARD- CARCINOMA• VARIABLE CONSISTENCY-

MALIGNANCY

HOW TO ASSESS CONSISTENCY

• SOFT – EAR LOBULE,ALAE OF NOSE

• FIRM- TIP OF NOSE,UN CONTRACTED MUSCLE

• HARD -BRIDGE OF NOSE,CONTRACTED MUSCLE

SIGN OF MOULDING OR INDENTATION

LOOK FOR THIS SIGN IN 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)

SEEN IN 1.SEBACYOUS CYST 2.DERMOID CYST 3.COLONIC MASS WITH FAECAL MATTER

PAGET’S TEST• DONE FOR SMALL SWELLINGS TO

KNOW THE CONSISTENCY(CYSTIC/SOLID)

• THE CENTRE AND PERIPHERIES ARE PALPATED WITH INDEX FINGER– CYSTIC SWELLING FEELS SOFTER AT

CENTRE THAN PARIPHERY– SOLID SWELLING FEELS FIRMER

ATCENTRE THAN PERIPHERY

SPECIAL TESTS

• DONE IN CASE OF SOFT/CYSTIC SWELLING– 7.FLUCTUATION– 8.TRANSILLUMINATION– 9.COUGH IMPULSE– 10.REDUCIBILITY– 11.COMPRESSIBILITY

• IN SOLID SWELLINGS DIRECTLY PROCEED TO TEST FOR RELATION TO OTHER STRUCTURES

7.FLUCTUATION

• TRANSMISSION OF IMPULSE IN TWO DIRECTIONS AT RIGHT ANGLES TO EACH OTHER

• IMPLIES PRSENCE OF FLUID IN THE SWELLING

HOW TO ELICIT FLUCTUATION?

IF THE SWELLING IS MOBILE FIRST FIX IT OR ASK THE ASST. TO HOLD IT

KEEP 2 INDEX FINGERS ON OPPOSITE POLES WHEN ONE FINGER IS PRESSED THE FINGER AT

OPPOSITE END FEELS THE IMPULSE & PASSIVELY LIFTED UP

REPEAT THE MANUVERE IN A PLANE AT RIGHT ANGLES TO THE 1ST ONE

IF IMPULSE IS FELT IN BOTH PLANES IT IS A POSITIVE FLUCTUATION TEST

LAW BEHIND FLUCTUATION!

• PASCAL’S LAW– PRESSURE EXERTED TO A FLUID IS

TRANSMITTED EQUALLY IN ALL THE DIRECTIONS

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PRINCIPLES WHILE DOING FLUCTUATION TEST

• ALWAYS PERFORM IN 2 DIRECTIONS AT RIGHT ANGLES TO EACH OTHER

• TWO FINGERS SHOULD BE KEPT AS FAR APART AS POSSIBLE

• FREELY MOBILE SWELLINGS SHOULD BE FIXED FIRST(AS IN HYDROCELE)

• SMALL SWELLINGS –WATCHING FINGER & DISPLACING FINGER

• VERY LARGE SWELLINGS MORE THAN ONE FINGFR SHOLD BE USED

PSEUDO FLUCTUATION

A FALSE SENSE OF FLUCTUATION FELT IN LARGE SOFT SWELLINGS CONTAINING NO FLUID

SEEN IN LARGE LIPOMA MYXOMA SOFT FIBROMA VASCULAR SARCOMA

FAIL TO EXPAND IN OTHER PARTS OF A SWELLING LIKE A TRUE FLUCTUANT SWELLING

CROSS FLUCTUATION

• FLUCTUATION BETWEEN TWO SEPARATE CYSTIC SWELLINGS COMMUNICATING WITH EACH OTHER

• SEEN IN– COMPOUND PALMAR GANGLION– PSOAS ABSCESS– PLUNGING RANULA

8.TRANSILLUMINATION

• DEMONSTRATION OF TRANSMISSION OF LIGHT THROUGH A SWELLING

• POSITIVE IN SWELLINGS CONTAINING CLEAR FLUID AND THIN TRANSPARENT WALLS

• NO TRANSILLUMINATION IF WALL IS THICK, OR TURBID FLUID IS PRESENT(BLOOD,PUS, LYMPH)

• DARK ROOM , TRANSILLUMINOSCOPE

BRILLIANTLY TRANSILLUMINANT SWELLINGS

1.CYSTIC HYGROMA

2.EPIDIDYMAL CYST

3.MENINGOCELE WITH THIN SKIN

4.RANULA

5.CONGENITAL HYDROCELE

9.COUGH IMPULSE• PERFORMED IN SWELLINGS LIKELY TO BE IN

CONTACT WITH ABDOMINAL ,CRANIAL ,SPINAL OR CHEST CAVITY

• SWELLING IS HELD WITH FINGERS AND PATIENT IS ASKED TO COUGH

• IF THE SWELLING BECOMES TENSE OR INCREASES IN SIZE IT IS POSITIVE COUGH IMPULSE

• IN CHILDREN CRYING ACTS AS COUGH

SWELLINGS WITH POSITIVE COUGH IMPULSE

• IN CONTINUITY WITH ABD. CAVITY– HERNIA– ILIO-PSOAS ABSCSS– LUMBAR ABSCESS

• IN CONTINUITY WITH PLEURAL CAVITY– EMPYEMA NECESSITANS

• IN CONTINUITY WITH SPINAL /CRANIAL CAVITY– SPINAL/CRANIAL MENINGOCELE

10.REDUCIBILITY• INDICATION SAME AS FOR COUGH

IMPULSE• PATIENT IS ASKED TO RELAX• SWELLING IS COMPRESSED FROM

ALL THE SIDES UNIFORMLY• REDUCIBLE SWELLINGS

DECREASESIN SIZE OR COMLETELY DISAPPEAR

REDUCIBLE SWELLINGS

• 1.HERNIA• 2.MENINGOCELE• 3.VARICOCELE• 4.SAPHENA VARIX

– A REDUCIBLE SWELLING ONCE REDUCED REAPPEARS ONLY BY STRAINING,COUGHING, OR FORCE OF GRAVITY AS IT INVOLVES DISPLACEMENT OF VISCERS TO AN ADJOINING CAVITY

11.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 FACTORLIKE STRAINING OR COUGHING

• CHARECTARISTIC SIGN OF VASCULAR HAEMANGIOMA

12.PULSATILITY WHEN FINGER IS PLACED OVER A PULSATILE

SWELLING IT RAISESWITH EACH BEAT TO TYPES OF PULSATIONS

TRANSMITTED PULSATIONS- SEEN IN SWELLINGS PRESENT NEAR AN ARTERY EX:CA STOMACH LUMP NEAR ABD.AORTA

EXPANSILE PULSATIONS-SEEN IN SWELLINGS ARISING FROM ARTERIES EX:AORTIC ANEURYSM

HOW TO DIFFERENTIATE?

• TWO FINGERS ARE PLACED OVER THE SWELLING AND FINGER MOVEMENTS ARE NOTED

• TRANSMITTED PULSATIONS – FINGERS ARE SIMPLY LIFTED UP

• EXPANSILE PULSATIONS- FINGERS ARE LIFTED UP AND MOVE APART

IN AN ABDOMINAL LUMP?• KNEE ELBOW POSITION

– WHEN KEPT IN KNEE ELBOW POSITION

• PULSATIONS DISAPPEAR – TRANSMITTED PULSATIONS

• PULSATIONS PERSIST –EXPANSILE PULSATIONS

13.FIXITY TO SKIN• SKIN PINCHED OVER DIFFERENT

PARTS OF THE SWELLING -CANNOT BE PINCHED IF FIXED TO SKIN

• SKIN IS MADE TO MOVE OVER THE SWELLING- THE SKIN WILL NOT MOVE IF IT IS FIXED TO SKIN

• SWELLINGS ARISING FROM SKIN ARE FIXED TO SKIN EX:SEBACEOUS CYST , PAPILLOMA , EPITHELIOMA

14.RELATION TO SURROUNDING STRUCTURES

• 1)SUBCUTANEOUS TISSUE– SWELLINGS IN SUB CUTANEOUS TISSUE ARE NOT

ADHERENT TO SKIN OR UNDERLYING MUSCLE– LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN

SOME PLACES – DUE PRESENCE OF FIBROUS SEPTA• 2)DEEP FASCIA

– SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS MOBILE AS SUBCUTANEOUS SWELLINGS

– IT IS DIFFICULT MAKE OUT FIXATION TO DEEP FASCIA AS DEEP FASCIA CANNOT BE MADE TAUT

• EVEN IF TUMOUR IS ATTACHED TO UNDERLYING DEEP FASCIA &MUSCLE TUMOUR CAN BE MOVED SIDEWAYS

3)RELATION TO MUSCLE• RELATION SHIP TO MUSCLE IS

KNOWN BY THROWING THE CONCERNED MUSCLE INTO CONTRACTION– TUMOURS IN SUB CUTANEOUS TISSUE-

BECOME MORE PROMINENT &REMAIN MOBILE

– TUMOURS ARISING FROM MUSCLE / INCORPORATED IN MUSCLE-FIXED&IMMOBILE

– TUMORS DEEP TO MUSCLE –LESS PROMINENT, OR DISAPPEARS,DIFFICULT TO PALPATE

4)SWELLING IN RELATION TO TENDON

MOVES ALONG WITH TENDON&BECOMES FIXED WHEN MUSCLE CONTRACTS

5)IN CONNECTION WITH VESSELS &NERVES DO NOT MOVE ALONG VESSELS OR NERVES BUT

MOVE TO A LITTLE EXTENT AT RIGHT ANGLES TO THEIR AXES

6)IN CONNECTION WITH BONE IS ABSOLUTELY FIXED IRRESPECTIVE OF MUSCLE

CONTRACTION

PERCUSSION

• LIMITED VALUE IN SWELLINGS– 1.TYMPANIC NOTE

• ENTEROCELE• PHARYNGOCELE

– 2.HYDATID THRILL• HYDATID CYST

3. Dull – solid swellings

AUSCULTATION

• BRUIT OVER PULSATILE &VASCULAR SWELLINGS

• BRUIT– SHORT,MEDIUM PITCHED MURMUR

HEARD OVER THE SWELLING WITH EACH PULSE WAVE

• EX:ANEURYSM• THYROTOXIC GOITRE

REGIONAL LYMPH NODES DRAINING LYMPH NODES EXAMINED IF

INVOLVED NEXT HIGHER GROUP EXAMINED IF THE SWELLING ITSELF IS ALYMPH NODE

EXAMINE 1.OTHER LYMPH NODAL GROUPS 2.SPLEEN 3.LIVER

TO EXCLUDE SYSTEMIC CAUSE EXAMINE DRAINAGE AREA TO EXCLUDE INFECTION

PRESSURE EFFECTS

• 1.OVER BONE – FEEL FOR BONY EROSION– AS IN DERMOID CYST

• 2.IN LIMBS– DISTAL PULSES- PRESSURE OVER ARTERIES– EDEMA &DILATED VEINS – PRESSURE OVER

VEINS– PARESIS& MUSCLE WASTING – PRESSURE

OVER NERVES• MOVEMENTS OF JOINTS

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WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE

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SPINAL LIPOMA

GENERAL EXAMINATION

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THANKS FOR PATIENT LISTENING