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Examination of the swelling
By
Dr.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 ATYPICAL POSITIONWHICH IS
DIAGNOSTIC
• EXAMPLES
– POST AURICULAR DERMOID-BEHIND EAR
– EXTERNAL ANGULAR DERMOID –LATERAL END
OF EYE BROW
– MENINGOCELE- OVERTHE 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 , SOMETIMES MULTIPLE
• MULTIPLE EXAMPLES
– MULTIPLE NEUROFIBROMATOSIS(VON RECK
LING HAUSENS DISEASE)
– MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)
– DIAPHYSEAL ACLASIS
– HYDRADENITIS SUPPURATIVA
– MULTIPLE LYMPHOGLANDULAR SWELLINGS
*Image via Bing
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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
BENIGN NEVUS
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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 , SHINYWITH PROMINENTVEINS – SARCOMA
• RED &EDEMATOUS – INFLAMMATORY
• BLACK PUNCTUM – SEBACEOUSCYST
• PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS
• SCAR
– PREVIOUSOPERATION(REGULAR SCARWITH 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
– 2TYPES
• EXPANSILE PULSATIONS – SWELLINGS ARISING
FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID
BODYTUMOUR
• TRANSIMITTED PULSATIONS – SWELLINGS CLOSE
TO ARTERIES
• REMEMBER NOTTOTOUCHTHE 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
• SAPHENAVARIX
– IN CHILDREN CRYING ACTS AS COUGHING
8.VISIBLE PERISTALSIS
• OBSERVED INABDOMINAL LUMPSAND
INGUINAL SWELLINGS
• CONGENITAL HYPERTROPHIC PYLORIC
STENOSIS –VISIBLE GASTRIC PERISTALYSIS
• INGUINAL HERNIAS (ENTEROCELE)
INTESTINAL PERISTALYSIS
• LUMPS DUETO 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
• ALONGWITHTHESETHYROID MOVES UP
11)MOVEMENT WITH TONGUE PROTRUSION
• IN CASE OF MID LINE NECK SWELLINGS
• EG:THYROGLOSSAL CYST &FISTULA
• WHY?
– ATTACHEDTO FORAMEN CAECUM OFTONGUE
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 DUETO
NON-USE/INJURY TO NERVES)
– SWELLING IN NECK WITHVENOUS
ENGORGEMENT(RETROSTERNAL EXTENSION)
PALPATION
• DEFINITE CLUETO DIAGNOSIS
• METHODICAL,FOLLOW DEFINITEORDER
• BE GENTLE
• SHOULD NOT HURTTHE PT.
1.TEMPERATURE
• IT IS AN ABSOLUTE STANDARD PRACTICE
TOTEST FORTEMP FIRST-WHY?
• BEST FELT BY BACK OFTHE HAND-WHY?
• INCREASED IN
– INFLAMMATORY SWELLING
– WELLVASCULARISEDTUMOURS- SARCOMA
2.TENDERNESS
• PAIN DUETO PRESSURE EXERTED OVER
THE SWELLING ISTENDERNESS
• PALPATE GENTLY OVER ALLTHE AREA
• IT IS A SIGN
• FEATURE OF
– INFLAMMATORY SWELLINGS
– SWELLING RELATEDTO NERVES -
NEUROFIBROMA
3.SIZE& SHAPE
• CONFIRMVERTICAL & HORIZONTAL
DIMENSIONS
• NOTETHETHIRD 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
*Image by 9085776@N08 via Flickr
ABSCESS WITH ILL DEFINED MARGINS
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LIPOMA WOTH WELL DEFINED MARGINS
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LARGE LIPOMA WITH WELL DEFINED MARGINS
*Image by 78523246@N00 via Flickr
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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
PALPATEDWITH A FINGER ,IF IT SLIPS
UNDERTHE FINGER,. DOES NOTYIELD
TO IT , IT IS A LIPOMA,IF IT YIELDSTO
FINGER IS A CYST
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6.CONSISTENCY
• SOFT – LIPOMA
• CYSTIC- CYSTS &CHRONIC ABSCESSES
• FIRM –FIBROMA
• HARD BUTYIELDING-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 SWELLINGSTO KNOW
THE CONSISTENCY(CYSTIC/SOLID)
• THE CENTRE AND PERIPHERIES ARE
PALPATEDWITH 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
TOTEST FOR RELATIONTO OTHER
STRUCTURES
7.FLUCTUATION
• TRANSMISSION OF IMPULSE INTWO
DIRECTIONS AT RIGHT ANGLESTO EACH
OTHER
• IMPLIES PRSENCE OF FLUID INTHE
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 EXERTEDTO A FLUID ISTRANSMITTED
EQUALLY IN ALLTHE DIRECTIONS
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PRINCIPLES WHILE DOING FLUCTUATION TEST
• ALWAYS PERFORM IN 2 DIRECTIONS AT
RIGHT ANGLESTO EACH OTHER
• TWO FINGERS SHOULD BE KEPTAS FAR
APART AS POSSIBLE
• FREELY MOBILE SWELLINGS SHOULD BE
FIXED FIRST(AS IN HYDROCELE)
• SMALL SWELLINGS –WATCHING FINGER &
DISPLACING FINGER
• VERY LARGE SWELLINGS MORETHAN 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 BETWEENTWO SEPARATE
CYSTIC SWELLINGS COMMUNICATING
WITH EACH OTHER
• SEEN IN
– COMPOUND PALMAR GANGLION
– PSOAS ABSCESS
– PLUNGING RANULA
8.TRANSILLUMINATION
• DEMONSTRATION OFTRANSMISSION OF
LIGHTTHROUGH A SWELLING
• POSITIVE IN SWELLINGS CONTAINING
CLEAR FLUID ANDTHINTRANSPARENT
WALLS
• NOTRANSILLUMINATION IFWALL ISTHICK,
ORTURBID 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 LIKELYTO BE IN
CONTACTWITH ABDOMINAL ,CRANIAL
,SPINAL OR CHEST CAVITY
• SWELLING IS HELDWITH FINGERS AND
PATIENT IS ASKEDTO COUGH
• IFTHE SWELLING BECOMESTENSE OR
INCREASES IN SIZE IT IS POSITIVE COUGH
IMPULSE
• IN CHILDREN CRYING ACTS AS COUGH