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Uthamalingam Murali, profile picture
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Swelling - Examination

The document outlines the evaluation of body swellings, detailing the definition, history taking, inspection, and physical examination techniques. It emphasizes the importance of history, including duration, onset, pain, and associated features. Various methods such as inspection, palpation, and auscultation are described to assess swelling characteristics, including size, shape, consistency, and relationship to surrounding structures.

Health & Medicine◦
Dr. U. Murali. M.S ; M.B.A. Prof. of Surgery D.Y.Patil Medical College Mauritius.
Meaning  Swelling denotes enlargement or protuberence in any part of the body.  It can be called as “Mass” – abd swelling or “Lump” – breast swelling.  Swelling in the skin means an eminence or elevation.
History  Chief complaints : - Swelling in any part of the body. - Associated with or without pain.  History of present illness : 1. Duration - - It is important to note the duration. 2. Mode of onset & progress – - It is very important so as to know whether it started after trauma or spontaneously.
History - contd - The rate of progress - whether rapid or slow. - Certain swellings may be stationary – status quo. - Side and exact site should be asked. - Size and shape - at the time of onset should be asked. 3. Pain – - Detailed history related to pain should be noted.
History - contd 4. Fever – - Nature of fever with the swelling should be asked . 5. Other lumps / swellings – - Any other swellings should be clarified. 6. Other features – - Secondary changes - Movements - Loss of wt & appetite
History - contd  Past history : - History of surgery in the past at the same site or at different site has to be asked for.  Personal history : - Habit of smoking / alcohol consumption or tobacco chewing. - Dietary habits and suffering from any chronic diseases and their treatment to be asked.
History - contd  Family history : - Family history suggestive of similar swellings should be enquired.  Treatment history : - As the patient has received any treatment for the present swelling and nature of treatment & its duration should be clarified.
Inspection  Examination of swellings starts with inspection. “ REMEMBER NOT TO TOUCH THE PATIENT DURING INSPECTION “  Typically remember first the “ 6 – S ” in the method of inspection.
1. Site  Exact anatomical location - noted  Relation – bony pt/ surface landmark  Eg :  Post Auricular Dermoid – Behind ear  Ext. Angular Dermoid – Lat. End of eye brow  Meningocele – Over the back in midline *Image via Bing *Image via Bing
2. Size  Vertical or Horizontal dimension - assessed  Noted in cms  Eg :  Ext. Angular Dermoid – Lat. End of eye brow.
3. Shape  Oval/globular/spherical pear or irregular – diffuse or localised  Eg :  Abscess – Over the back
4. Surface  Smooth / nodular / lobular or irregular  Eg :  Smooth – Seb. cyst  Nodular – MNG-Thyroid *Image via Bing
5. Skin  Tense, glossy with prominent veins  Red edematous  Pigmentation/ulceration/ fungation / discharge  Scar & nature of healing  Eg:  Abscess – Back  Abd.wall abscess
6. Surrounding area  Changes - pigmentation/edema wasting, discoloration  Eg :  Abscess – Rt. foot  Ca. Breast *Image by 9085776@N08 via Flickr
7. Others  Number – single multiple  Colour  Edges / Margins  Extent  Visible pulsations  Visible cough impulse  Movements  Joints – above / below
Palpation  Be Gentle & do not hurt the patient  Methodical, follow a definite order  To define anatomically  To find out – nature of content
1. Temperature  Check in the beginning itself  Best – back of hand  Increased in - - Inflammation / Infection - Tumours with ↑ vascularity
2. Tenderness  Pain due to pressure exerted over the swelling  Palpate gently – observe the face of patient  Features of : - Inflammatory conditions - Swellings related to nerves
3. Inspectory findings  Size, Shape, Surface, Edge and Extent – confirm with palpation & co-relate both.  Note the third dimension depth which could not be exactly determined by inspection.
4. Consistency  Nature or feel of the swelling  Look for - Moulding  Look for this sign – Soft & Cystic swellings  Press a finger for 1-2mts & release it. If swelling remains indented it indicates the content is a pulltaceous or putty – like material.  Uniform : - Soft: lip/ear lobule - Firm: tip of nose - Hard: forehead  Variable :
5. Fluctuation  Transmission of impulse in 2 directions at right angle to each other.  Implies – fluid or gas  Pseudo-fluctuation  Cross-fluctuation  Eliciting method –  First fix the swelling.  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 manouevre in a plane at right angles to the 1st one.  If impulse is felt in both planes it is a + fluctuation test.
Fluctuation - contd  Pagets’s test - < 2cm  The margins of swellings is fixed using thumb & ring fingers.  Using index finger summit or centre of swelling is pressed to feel the displacement of fluid.  Principles to be used –  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 .  Very large swellings more than one finger should be used.
6. Translucency  Transmission of light through a swelling.  Positive in swellings – Clear fluid & thin transparent walls.  No transillumination - wall is thick, or turbid fluid [ Blood,pus,lymph ]  Dark room with transilluminoscope.
7. Reducibility Pt is asked to relax first. Swelling is pressed from all sides uniformly. Reducible swellings decreases in size or completely disappear. It reappears only by straining, coughing. It involves displacement of viscera to an adjoining cavity. 1. Hernia 2. Meningocele 3.Varicocele 4. Saphena varix
8. Compressibility Sweling on pressure reduces in size only partially but will not disappear completely. Swelling regains its original form on releasing the pressure. Contents are not actually displaced. 1. Haemangiomas 2. Lymphangiomas
9. Pulsatility  Swelling may be pulsatile – It raises with each beat.  2 types of pulsations - seen.  Two fingers are placed over the swelling and finger movements are noted. 1.Transmitted pulsation – Fingers are only raised but not separated. 2.Expansile pulsation – Fingers are raised & separated.
10. Fixity to skin  Skin is lifted up over different parts of the swelling – cannot be lifted if fixed to skin.  Skin is made to move over the swelling – the skin will not move if it is fixed to skin.
11. Mobility/Plane-swelling  Mobility – swelling can be moved in relation to underlying structures.  Plane – co-relates to the probable site of origin or its relationship to deep fascia.
12. Relationship to structures  Muscle – - Sub. Cut.Tissue : more prominent & less mobile. - From muscle : fixed & diminished - Deep to muscle : disappears & difficult to palpate  Tendon – - Moves with the tendon & fixed  Vessels & nerves – - Moves little extent at rt angles to axis.  Bone – - Fixed
Percussion  Limited value in swellings  Not needed  To find out content or elicit tenderness
Auscultation  Look for any bruit over pulsatile swellings.  Machinery murmur – aneurysmal varix
Other examinations Joints above & below the swelling – movements. Look for pressure effects. Regional lymph nodes – enlargement Systemic examination – related to respiratory / skeletal & abdomen – suspecting malignancy.
Swelling - Examination