Summary of swelling physical examination

1. Swelling
Examination
Khaled El Zorkany, MD
Ass. Professor
Internal Medicine & Nephrology
King Faisal University

2. Objectives
Write A report on swelling.
Items should be fulfilled on swelling
report .
Do head & neck examination
professionally

3. Swelling (Lump)
Swelling denotes enlargement or
protuberance in any part of the body.
Approach to swelling ?
History
Examination
Investigations

4. Examination of Swelling (Lump)
Inspection
Palpation
Percussion
Auscultation

5. Instructions before
examination
Clean and warm hands and remove
jewellery
Greeting patient and explain the
procedure
Instruct patient as what clothing to
remove and what position to adopt
Basics of palpation

6. Inspection
1. Number (single or multiple)

9. Inspection
2. Site
Medial Or Lateral, Ventral Or Dorsal, cranial or
caudal, distal or proximal.
Relation to another structure
Make a drawing
Anatomical region

11. Inspection
3. Shape
Rounded, globular, oval, bean-shaped,…..

12. Inspection
4. Size (estimated)
 e.g. orange, lemon, melon..)

13. Inspection
5. Surface
Smooth, lobulated, irregular

14. Inspection
6. Skin over
Dilated veins, pigmentation, ulceration,
previous incision,…..

17. Inspection
7. Circumscription (Edge)
A circumscribed swelling is clearly delineated
from the surrounding area,
whereas an uncircumscribed swelling appears
rather to merge with the surrounding tissue.

20. Arterial haemangioma – bright red
Venous haemangioma— purple
Malignant melanoma- black
Benign naevus – black
Ranula –blue
7- Color
Inspection

21. Color

24. Pulsation – a movement or increase in size
synchronous with each heart beat
2 types:
 Expansile (true) pulsations – swellings
arising from arteries ex: aortic aneurysm ,
carotid body tumor •
Transmitted pulsations – swellings close
to arteries
 With palpation
7- Visible pulsations
Inspection

25. 8-Visible Cough Impulse
Performed when swelling is over a cavity
(abdomen, chest, spinal canal or cranium)
Cough impulse
 Visible increase in the size of swelling
synchronous with cough.
Positive in swellings communicating with
cavity.

26. Positive Cough Impulse
Swellings with positive cough impulse :
 With abdominal Cavity – hernia – ilio-
psoas abscess – lumbar abscess
 With pleural cavity – empyema
necessitans.
 With spinal /cranial cavity – spinal/cranial
meningocele.

27. Movement with deglutition
Should be elicited 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

28. Movement With Tongue Protrusion
In case of mid line neck swellings eg:
thyroglossal cyst &fistula
Why? – Attached to foramen caecum of
tongue

29. 9-Pressure Effects
When swelling is present on limbs:
– An axillary swelling with limb edema – lymph
nodal 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)

30. Palpation
1. Size, Shape, Surface, and Extent –
confirm with palpation & co-relate both.
Note the third dimension depth which
could not be exactly determined by
inspection.

31. Palpation
 Check in the beginning
 Best – back of hand or fingers
 Increased in:
 Inflammation / Infection
 Tumors with ↑ vascularity (sarcoma)
2. Temperature

32. Palpation
3. Tenderness
Refers to pain or additional pain caused by
touching the swelling and exerting pressure on
it.
Palpate gently – observe the facial expression
Features of : -
Inflammatory conditions
Swellings related to nerves (Neurofibroma)

33. Palpation
1) well defined & regular – benign neoplasms
2) well defined & irregular – malignant
neoplasm
3) Illdefined & diffuse –inflammatory swellings
4. Edge

34. Palpation
5. Consistency
How to assess consistency ?
 Soft – ear lobule (lipoma, cysts & chronic
abscesses)
 Firm-tip of nose (fibroma)
 Hard -bridge of nose, Forehead
(chondroma, osteoma)
 Variable (malignancy)

35. Soft swellings
Cystic/Solid
Fluctuation & Paget's tests
Fluctuation test (large swelling)
 if swelling contains fluid in a enclosed
space, it will fluctuate.
Transmission of impulse in 2 directions at
right angle to each other.

36. 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 maneuver in a plane at right
angles to the 1st one.
If impulse is felt in both planes a +
fluctuation test.

37. Palpation
Paget's test : done for small swellings to
know the consistency(cystic/solid)
The margins of swellings is fixed using
thumb & ring fingers.
Using index finger, summit or center of
swelling is pressed to feel the displacement
of fluid and center feels softer than
periphery (cystic one) while firmer at center
than periphery (solid swelling)

38. Palpation
Relation to skin
Relation to Muscle
Relation to Tendons
5. Relation to surrounding structures

39. Palpation
I. Relation 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 , epitheliom

40. Palpation
Relationship to muscle is known by throwing
the concerned muscle into contraction –
Tumors in subcutaneous tissue- become more
prominent & remain mobile
Tumors arising from muscle / incorporated in
muscle- fixed & immobile
Tumors deep to muscle – less prominent, or
disappears, difficult to palpate
II. Relation to muscle

41. Palpation
Moves along with tendon & becomes fixed
when muscle contracts
III. Relation to tendon
III. Relation to vessels &nerves
III. Relation to bone
Do not move along vessels or nerves but
move to a little extent at right angles to their
axes
Is absolutely fixed irrespective of muscle
contraction

42. Palpation
7. Reducibility
 Performed when swelling is over a
cavity (abdomen, chest, spinal canal or
cranium)
 Patient is asked to relax
 Swelling is compressed from all the sides
uniformly
 Reducible swellings completely disappear

43. Reducible swellings:
Hernia
Meningocele
Varicocele
Saphena varix
A Reducible Swelling once reduced
reappears only by straining, coughing, or
force of gravity.

45. Compressibility
When pressure is applied to a swelling it
decreases in size but will not disappear
completely and when pressure is released
swelling regains its size itself with out any
external factor like straining or coughing
Characteristic sign of vascular haemangioma
& Lymphangiomas

46. Palpation
8. Pulsation
When finger is placed over a pulsatile
swelling it raises with each heart beat
Tow 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

47. How to differentiate between transmitted and expansile pulsations
If you are palpating a swelling like an abdominal swelling infront of the aorta, You have
to decide whether the mass you feel is pulsatile/expansile in itself (in which case
your fingers will move outwards A ) or whether the pulsation is transmitted through
other tissue (in which case your fingers will move upwards B ).See diagram
below
Also in transmitted pulsation you can make this pulsation disappear if you can move
the swelling away from the aorta ( if you put the patient in the knee-elbow position, an
enlarged intra-abdominal swelling which was transmitting aortic pulsation will get away
from the aorta and the pulsations will disappear)

48. How to differentiate?
In an abdominal lump?

49. 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.

50. How to differentiate?
In an abdominal lump?
Knee elbow position – when kept in
knee elbow position:
 Pulsations disappear –transmitted
pulsations
 Pulsations persist –expansile pulsations

52. 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 with transilluminoscope

53. Transillumination
Light transmission is visible as a red glow. If
light transmission is visible we refer to the
swelling as ‘diaphanous’ or ‘translucent’
(permitting the passage of light).
Also compare this with the amount of light
transmitted adjacent to the swelling
E.g. Hydrocele, Ranula

55. Percussion
Limited value in swellings:
1.Tympanic note • Enterocele • Pharyngocele
2. Dull – solid swellings

56. Auscultation
Bruit heard over pulsatile & vascular
swellings
Bruit:
 Short, medium pitched murmur heard
over the swelling with each pulse wave
 ex: Aneurysm, Thyrotoxic goitre, Saphena
varix
Intestinal sounds in the case of an
umbilical hernia.