History taking & physical examination of lump

For medical Student
11/7/2021
Dr: Ayub Abdulkadir Abdi 1

History of lump:
1. When did you noticed it?
2. How did you noticed it?
3. Is the lump symptomatic? Pain, pressure.
4. Any change in size since first noticed?
5. Does the lump ever disappeared or reduced in
size?
6. Any other lump in the body?
7. Any cause? trauma? Heavy weight lifting?
11/7/2021 Dr: Ayub Abdulkadir Abdi 2

1_ When was the lump first noticed?
• It is important to be precise with dates and
terminology.
• Do not write ‘the lump first appeared 6 months
ago’, when you mean ‘the lump was first noticed 6
months ago’.
• Many lumps may exist for months, even years,
before the patient notices them.

2_ What made the patient notice the lump?
• There are four common answers to this
question:
a) ‘I felt or saw it when washing.’
b) ‘I had a pain and found the lump when I felt the
painful area.’
c) ‘Someone else noticed it and told me about it.’
d) ‘I found it on self examination’, for example a
breast lump in a female.

3_ What are the symptoms of the lump?
• The lump may be painful, and if it is, you
must take a careful history of the pain.
• Pain is usually associated with inflammation, not
neoplastic change.
• Many patients expect cancer to be painful and
ignore a malignant lump just because it does not
hurt.
• A lump may be disfiguring or interfere with
movement, respiration or swallowing.

4_ Has the lump changed since it was first noticed?
• The patient should be able to tell you if
the lump has got bigger or smaller, or has
fluctuated in size and when they noticed
a change in size.
• They may also have appreciated other changes
in the nature of the lump that they can tell
you about.

5_ Does the lump ever disappear?
• A lump may disappear on lying down, or
during exercise, and yet be irreducible at the
time of your examination.
• The patient should always be asked if the
lump ever disappears completely, because this
physical characteristic is peculiar to only a few
types of lump.

6_ Has the patient ever had any other lumps?
• You must ask this question because it might
not have occurred to the patient that there
could be any connection between their present
lump and a previous lump, or even a coexisting
one (e.g. neurofibromas or lipomas).

7_ What does the patient think caused the lump?
• Lumps occasionally follow injuries or systemic
illnesses known only to the patient

Examination of lump:
1. Site
2. Size
3. Shape
4. Surface
5. Colour
6. Temperature
7. Tenderness
8. Edge
9. Composition:
• Consistency
• Fluctuation
• Fluid thrill
• Translucency.
• Resonance
• Pulsatility
• Compressibility
• Bruit
11. Reducibility
12. Relations to surrounding
structures – mobility/ fixity
13. Regional lymph glands
14. State of local tissues:
• Arteries
• Nerves
• Bones and joints

1= Site:
• The location of a lump must be described in exact
anatomical terms, using distances measured from
bony points.
• Do not guess distances; use a tape measure.

2= Size:
• Once the shape has been established, it is possible to
measure its dimensions.
• Remember that all solid objects have at least three
dimensions: width, length and height or depth, although
the latter may be impossible to measure clinically.
• Asymmetrical lumps will need more measurements to
describe them accurately, and sometimes a diagram will
clarify your written description.
• The size are:
a) Small.
b) Large.
c) Huge.
Horizontal and vertical

3= Shape:
• Remember that lumps have three dimensions.
• You cannot have a circular lump because a circle
is a plane figure.
• Many lumps are:
a) Ovoid.
b) Pear shaped.
c) Spherical.
d) Elliptical or hemispherical.
e) Irregular.

Oval shaped Pear shaped

4= Surface:
• It may be:
a) Smooth.
b) Irregular.
• An irregular surface may be covered with
smooth bumps, rather like cobblestones, which can
be called bosselated, or may be irregular or rough.
• There may be a mixture of surfaces if the lump
is large.

Smooth Irregular
Cobblestones

5= Color and texture of the
overlying skin:
• The skin over a lump may be:
a) Discolored.
b) Inflamed.
c) Smooth and shiny.
d) Thick and rough.

Discolored
Inflamed
Smooth and shiny
Thick and rough

6= Temperature:
• Is the lump hot or of normal temperature?
• Assess the skin temperature with the dorsal
surfaces of your fingers, because they are usually
dry (free of sweat) and cool.

7= Tenderness:
• Is the lump tender?
• If so, is the whole lump tender?
• Always try to feel the non-tender part before feeling
the tender area, and watch the patient’s face to ensure
that you are not causing discomfort as you palpate.

8= Edge:
• The edge of a lump may be:
a) Clearly defined.
b) Indistinct.
• It may have a definite pattern.

9= Composition:
• Any lump must be composed of one or
more of the following:
a) Bony-hard _ calcified tissues such as bone, which
make it
b) Solid or firm or rubbery _ tightly packed cells, it
depending on the tissue of origin and the individual’s
stromal response.
c) Soft and Cystic _ extravascular fluid, such as urine,
serum, cerebrospinal fluid, synovial fluid or
extravascular blood.
d) Gas _ which makes it soft and compressible.
e) Intravascular blood _ which makes it pulsatile.

Consistency:
• The consistency of a lump may vary from very soft
to very hard.
• As it is difficult to describe hardness, it is common
practice to compare the consistency of a lump to
well-known objects.
• A simple scale for consistency is as follows:
a) Stony hard: not indentable – usually bone or
calcification.
b) Firm: hard but not as hard as bone – similar to an
unripe apple or pear.

c) Rubbery but slightly squashable – similar to a
rubber ball.
d) Spongy: soft and very squashable, but still with
some resilience, like a sponge.
e) Soft: squashable and with no resilience, like a
balloon.
• The consistency of a lump is dependent not only
upon its structure, but also on the tension
within the lump.
• Some fluid-filled lumps feel hard, some solid
lumps are soft.

Fluctuation:
• Pressure on one side of a fluid-filled cavity makes all
the other surfaces protrude.
• This is because an increase of pressure within a cavity is
transmitted equally and at right angles to all parts of its
wall.
• When you press on one aspect of a solid lump, it may
or may not bulge out in another direction, but it will
not bulge outwards in every other direction.
• Fluctuation is elicited by feeling at least two other
areas of the lump between the thumb and index
finger of the left hand while pressing on a third
central point with the index finger of the right hand.

Fluid thrill:
• A percussion wave is easily conducted across a
large fluid collection or cyst but not across a
solid mass.
• The presence of a fluid thrill is detected
by tapping one side of the lump, by flicking the
middle finger of the right hand against the thumb,
and feeling the transmitted vibration when it
reaches the other side, where the second detecting
left hand is placed.
• When it is present, a fluid thrill is a diagnostic and
extremely valuable physical sign.

• Beware – a percussion wave can be transmitted along
the wall of a large swelling.
• This is prevented by placing the edge of the patient’s
or an assistant’s hand on the lump midway between
the percussing and palpating hands.
• Percussion waves cannot be felt across small fluid-filled
lumps because the wave moves so quickly that the time
gap cannot be appreciated or distinguished from the
mechanical shaking of the tissue caused by the
percussion.

Translucency
(Transillumination):
• Light passes easily through clear fluids but does not
pass through solid tissues. A lump that
transilluminates must contain water, serum, lymph
or plasma.
• Highly refractile light can also appear to
transilluminate through a large lipoma, while blood
and other opaque fluids do not transmit light.

• Transillumination requires a bright pinpoint
light source and a darkened room.
• The light should be placed on one side of the lump,
not directly on top of it.
• Transillumination is present when the whole lump
glows at a distance from the light source.
• Attempts at transillumination with a poor-quality
flashlight in a bright room are bound to fail and
mislead.
•The room must be really dark!

Resonance:
• Solid and fluid-filled lumps sound dull when
percussed.
• A gas-filled lump, such as a hernia sac containing
bowel, sounds hollow and resonant.

Pulsatility:
• Lumps may pulsate because they are near to an
artery and are moved by its pulsations (transmitted
pulsation) or because they are connected with the
heart or arterial system (expansile pulsation).
• The most common cause of expansile pulsation is
an aneurysm, with, rarely, very vascular tumours.

• Always let your hand rest still for a few seconds on
every lump to discover if it is pulsating.
• When a lump pulsates, you must find out whether
the pulsations are transmitted or are expansile.
• Place a finger (or fingers if the lump is large) of
each hand on opposite sides of the lump and feel if
they are pushed outwards and upwards.
• When they are, the lump has an expansile pulsation
‘true pulsating’.
• When they are pushed only upwards, the lump has
a transmitted pulsation ‘false pulsating’.

Compressibility:
• Some fluid-filled lumps can be compressed until
they disappear.
• When the compressing hand is removed, the lump
re-forms.
• This finding is a common feature of vascular
malformations and fluid collections that can be
pushed back into a cavity, a joint or a cistern.
• Compressibility should not be confused with
reducibility.

Reducibility:
• Gently compressing it.
• A reducible lump becomes smaller and then moves to
another place as it is compressed.
• It may disappear quite suddenly after appropriate
pressure has been applied.
• The lump may return, when you ask the patient to
cough, expanding as it does so.
• This is called a cough impulse and is a feature of
hernias and some vascular lumps.
• The reduction can be maintained by pressing over the
point at which the lump finally disappeared.

Bruits:
• Always listen to a lump.
• A systolic bruit or a machinery murmur (throughout
both systole and diastole) may be audible over
vascular lumps that contain an arteriovenous
fistula.
• Audible bowel sounds can be heard over a hernia
containing bowel.

10= Relations to surrounding
structures:
• Superficial:
• The attachment of skin and other superficial structures
to a lump can easily be determined.
• The lump should be gently moved while the skin is
inspected for movement or ‘puckering’.
• The lump is attached to the fascia covering the
superficial surface of the muscle or to the muscle itself.
• Deep:
• Attachment to deeper structures is more difficult
to determine.
• The lump is within or deep to the muscles.

Superficial: Deep:

• The underlying muscles must be tensed to see if
this reduces the mobility of an overlying lump or
makes it easier or more difficult to feel.
a) Lumps that are attached to bone move very little.
b) Lumps that are attached to or arising from vessels
or nerves may be moved from side to side, but
not up and down.
c) Lumps in the abdomen that are freely mobile
usually arise from the intestine, its mesentery or
the omentum.

11= State of the regional lymph
glands:
• Never forget to palpate the lymph glands that
would normally drain lymph from the region
occupied by the lump:
a) the skin, muscles and bones of the limbs and
trunk drain to the axillary and inguinal glands.
b) the head and neck to the cervical glands.
c) the intra-abdominal structures to the preaortic
and para-aortic glands.

12= Local tissues:
• It is important to examine the overlying and nearby
skin, subcutaneous tissues, muscles and bones, and
the local circulation and nerve supply of adjacent
tissues.
• This is more relevant when
examining an ulcer, but some lumps are
associated with a local vascular or neurological
abnormality, so this part of the examination must
not be forgotten, as for example skin ulceration can
occur over a locally advanced breast cancer.

Finally:
General examination

History taking & physical examination of lump

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