This document provides guidance on evaluating a patient presenting with an abdominal lump. It outlines taking a thorough history including demographics, present complaints, past medical history, and family history. A comprehensive physical exam of the abdomen is described including inspection, palpation, percussion, and auscultation. Differential diagnoses are discussed depending on the location of the lump in the hypogastric region. Investigations guided by history and exam such as ultrasound and organ-specific tests are recommended to determine the nature and origin of the lump.

1. Approach to a patient with
hypogastric lump
Dr.Ankita Singh
Assistant Professor
General Surgery
L.H.M.C.

2. Objectives
Adopt sequential approach to a patient
complaining about abdominal lump by
• Extracting relevant history
• Thorough clinical examination
• Clue to right diagnosis by conducting
investigations guided by above history &
examination
• Offering adequate treatment

4. history
Demography:
• Age
• Gender
• Occupation
• Address
• Socio economic status

5. History…
Presenting complaints:
• Abdominal lump: appearance, duration,
site, approx. Size, progression/regression, any
association with posture/ straining/
trauma/*pain, disappears spontaneously
• Pain: site, onset, duration, character,
radiation/migration/referred, any relieving
/aggravating factors

6. History …
other associated complaints-
• Nausea/vomiting: character, amount,
frequency, content (hemetemesis),
relieving/aggrevating factors,
• Altered bowel habit: diarrhea, constipation,
obstipation, flatulent dyspepsia etc
• Melaena/hematochezia
• Jaundice: onset, duration,progression etc.

7. History…
• Associated fever episodes
• Appetite
• Weight loss
• Any other relevant history

8. History…
Past & personal history:
• Comorbidity/ treatments- medical or
surgical
• Sleep-wake cycle/ eating habits/ appetite/
bladder & bowel habits/ substance abuse
Family/ menstrual & obstetric history

9. Physical examination
Prerequisites: Consent, environment, chaperon
General survey:
• built, nutrition, mentation
• vitals
• signs-pallor, icterus, cyanosis, pedal edema,
lymphadenopathy, clubbing.
Systemic examination:
• CNS/Respiratory/Cardiovascular
examination

10. Physical examination
• Abdominal examination:
Inspection:
1. Contour (normal/scaphoid/obese/distension),
symmetric/asymmetric
2. Skin- scars, pigmentation, signs of inflammation,
wounds/ulcer, engorged veins etc
3. Umbilicus- position
4. Visible abnormal protuberance/lump
5. Movement-with respiration/peristalsis/pulsations
6. Hernial orifices

11. Right
hypochondrium
Epigastrium Left
hypochondrium
Right lumbar Left lumbar
umbilical
Right iliac fossa left iliac fossa
Hypogastrium
Right upper quadrant Left upper quadrant
Right lower quadrant Left lower quadrant

12. Physical examination
Palpation:
1. Tenderness
2. Soft/tense/distention
3. Temperature
4. Palpable organomegaly & its description
5. Palpable lump: site, tenderness, size, surface,
shape, consistency, *margins, *movement
(respiration/??direction/ballotable),
pulsatile(transmitted/expansile), *intraperitonial
vs parietal wall vs retroperitonial.
6. Hernial sites

13. Physical Examination…
*The abdominal muscles made taut by asking
patient
(i) to raise his shoulders from the bed with
the arms folded over the chest —
the 'rising-test' or
(ii) to raise both the extended legs from the
bed — the 'leg lifting test’(Carnett's test) or
(iii) to try to blow out with his nose and
mouth shut.

14. Physical examination
• If the swelling is parietal:
– the swelling will be more prominent when the
abdominal muscles are made taut and will be
freely movable over the taut muscle.
– but if fixed to the abdominal muscle the swelling
will not be movable when the muscles are made
taut
• Another differentiating point is that if the
swelling moves vertically with respiration it is
obviously an intra-abdominal swelling.

15. Physical examination
Percussion:
1. Technique for lump
2. Technique for evaluation of ascites
3. Span of organomegaly
*solid lump-dull(superficial),resonant(coils of
bowel overlying)
#Band of colonic resonance
~Hydatid thrill

16. Auscultation:
1.Bowel sounds
2.Abnormal sounds (bruit, hums)

17. Physical examination…
• Scrotal examination
• Left supraclavicular lymph nodes examination
• Rectal & vaginal examination

18. Differential diagnosis of hypogastric
lump

19. Hypogastrium Right lower quadrant Left lower quadrant

21. Lump in hypogastrium
*Urinary bladder must be emptied prior
PARIETAL LUMP: any subcutaneous lesion,
hematoma /abscess, urachal cyst
INTRA ABDOMINAL LUMP:
1. Urinary bladder: urinary retention, bladder
mass
2. Uterus & adnexa: gravid, large fibroid, tubo
ovarian mass, ruptured tubal ectopic, cysts,
tumours

22. Investigations
To confirm diagnosis, based on site:
1. USG abdomen-
origin of lump, nature, involvement of adjacent
structures, ??any other findings
2. Organ specific
3. Supporting blood investigations and imaging

23. Thank you
Any queries?