HISTORY how long is the lump present? when was the lump first noticed? There is a heaven and hell difference between these two questions. Pain less lump may present for along time with out patients knowledge.
SHORTDURATION&PAIN: INFLAMMATORY SINCE BIRRTH:CONGENITAL LONGER DURATIONWITH OUT PAIN :BENIGN LONGER DURATION WITH PAIN AND SHORT DURATION- ------------MAYBE MALIGNANT
What is your diagnosis? DURATION: SINCE BIRRTH:CONGENITAL
MODEOF ONSET HAVE APPEARED AFTER TRAUMA ;fractured displacement of bone,dislocation of joint,haematoma DEVELOPED SPONTANEOUSLY AND GROWN RAPIDLY WITH PAIN: inflammatory GRADULLY INCREASING INSIZE: neoplasm SWELLING APPEARED IN PRE EXISTING CONDITION: keloid from previous scar, malignant melanoma from previous benign nevus
OTHER SYMPTOMS PAIN----inflammatory or involving nerves DIFFICULTY IN RESPIRATION---pressure on trachea DIFFICULTY IN SWALLOWING--- pressure on esophagus INTERFFERING WITH MOVEMENT—swellings near joint DISFIGURATION
pain Nature of pain: throbbing pain suggests inflammation leading to suppuration.pain may be burning,stabbing,aching. Site:most offen pain is localised to the site of swelling. referred pain may be present Time of onset: in inflammatory swellings.pain appears even before the swelling.but in case of tumors swelling appears long before pain.in malignant conditions pain is due to involvement of nerves,fungation,ulceration,deepinfiltration,which indicates inoperability
PROGRESS OF THE SWELLING GROWING SLOWLY-------benign swellings GROWING QUICKLY--------malignant swellings SUDDENLY INCREASING IN SIZE AFTER REMAINING STATIONERY FOR SOME TIME----malignant transformation of benign swellings DECREASING IN SIZE------inflammatory swellings
EXACT SITE: site of the swelling tells from which organ the swelling was originated. PSENCEOF OTHER LUMPS: neurofibromatosis,diaphysial aclasia,hodgkins lymphoma may present with multiple swellings.
PSENCE OF OTHER LUMPS: neurofibromatosis,diaphysial aclasia,hodgkins lymphoma may present with multiple swellings.
RECURRENT SWELLINGS---malignant swellings, malignant growth in benign swellings.certain swellings like pagets recurrent fibroid,known for recurrence.cystic swellings may recur if they are not removed completely.
RECURRENT SWELLINGS—parotidadenoma recurred after surgery
Dermato sarcoma protuberance ----------------------------known for recurrence
LOSS OF BODYWEIGHT-- malignant&tuberculosis LOSS OF APPETITE-- malignant&tuberculosis - HISTORY OF FEVER—acute& chronic, inflammatory swellings, malignant swellings, lymphomas
PAST HISTORY; important in tuberculosis FAMILY HISTORY: important in carcinoma breast,medullary carcinoma thyroid, PERSONAL HISTORY: smoking and alcoholism are risk factures for several malignancies
LOCAL EXAMINATION SITE OF THE SWELLING: a few swellings are peculiar in their positions such as dermoid cyst are mostly seen in the mid line of the body or on the line of the fusion of embryonic processes.eg.at the outer canthus of eye---that means on the line of fusion between the fronto-nasal process and the maxillary process.or behind the ear (post auricular dermoid)--- on the line of fusion of the mesodermal hillocks which form the pinna. SHAPE OF THE SWENG;ovoid,sperical,irregular
DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
COLOUR OF THE SWELLING:colour of the swelling give a definitive hint to the diagnosis. black color of benign nevus and malignant melanoma, red/purple color of haemangioma. bluish color of ranula are obvious and diagnostic
SURFACE: in certain swellings suface may be very much obvious and diagnostic. cauliflower surface of squamous cell carcinoma, irregular numerous branched surface of papilloma.
Papilloma from nipple ---------------------------------------------------irregular numerousbranched surface of papilloma.
NUMBER: this is important as this may give a clue to the diagnosis. some swellings are always multiple such as neurofibromatosis,diaphysial aclasia,hodgkins lymphoma some swellings are more known to be solitary ,eg.lipoma,dermoid cysts
PULSATION: swellings arising from the arteries are pulsatile,eg.aneurysm and vasculargrowth such as carotid body tumor. These give expansile pulsations.some swellings present over the arteries will be pulsatile.these will give transmitted pulsations SKIN OVER THE SWELLING: red edematous in inflammatory swellings.tense,glossy with venous prominence in sarcoma with rapid growth. presence of black punctum in sebaceous cyst.presence of scar indicates previous operation(when the scar is linear with suture marks) previous injury(regular scar),previous suppuration(puckered,broad,irregular scar)
SLIP SIGN BOTH LIPOMA AND CYST HAVE SMOOTH MARGINNS LIPOMA SLIPS AWAY ON PALPATION CYST YIELDS ON PALPATION
CONSISTANCY IT DEPENDS ON WHAT IT IS MADE UP OF CYSTIC FIRM HARD UNIFORM IN COSISTACY OR VARIABLE IN CONSISTACY
FLUCTUATION SWELLING FLUCTUATES WHEN IT HAS FLUID FIRST TO FIX THE SWELLING THIS TEST SHOULD BE PERFORMED IN TWO PLANES PAGETS TEST
TRANSLUSENCY THIS MEANS SWELLING TRASMITS LIGHT WHEN IT HAS CLEAR FLUID LIKE WATER,LYMPH,SERUM,PL ASMA NOT TRANSULANT WHEN IT CONTAINS OPAQUE FLUID LIKE BLOOD,PUS,PULTAEOUS MATERIOL Translucency brilliantly Positiveinhydrocele,ranula ,cystic hygroma
IMPULSE ON COUGHING SWELINGS WHICH HAVE CONTINUITY WITH ABDOMINAL CAVITY-HERNIA SWELLINGS WHICH HAVE CONTINUITY WITH SPINAL CORD-MENINGOCELE WHICH HAVE CONTINUITY WITH PLEURAL CAVITY- EMPYEMA NECESSITANCE SWELLING IS PALPATED IN FINGURES AND ASKED TO COUGH AN IMPULSE WILL BE FELT DUE TO INCREASE PRESSURE IN THESE CAVITIES INCASE OF CHILDREN THIS IS PERFORMED WHEN THEY CRY
SWELINGS WHICH HAVE CONTINUITYWITH ABDOMINAL CAVITY-HERNIA
SWELLINGS WHICH HAVECONTINUITY WITH SPINAL CORD-MENINGOCELE
REDUCIBILITY SWELLING REDUCES AND ULTIMATELY DISSAPPEARS AS SOON AS PRESS UP ON Does not appear on removal of swelling Appears after increase in counter pressure THIS IS A FEATURE OF HERNIA LYMH VARIX,VARICOCELE,SAPHENA VARIX,MENINGOCELE ARE REDUCIBLE PARTLY OR COMPLETELY
SWELLING REDUCES AND ULTIMATELYDISSAPPEARS AS SOON AS PRESS UP ON HERNIA
COMPRESSIBILITY THE SWELLING CAN BE COMPRESSED BUT NOT BE DISSAPPEARED COMPLETELY THE SWELLING REAPPEAS WHEN PRESSURE IS TAKEN OFF HAEMANGIOMA,LYMPHANGIOMA
PULSATILITY ARISING FROM ARTERY--EXPANSILE PULSATION- ANEURISM VERY CLOSE TO ARTEY---TRANSMITTED PULSATION SWELLING IS HIGHLY VASCULAR----------- TELANGIECTATIC SARCOMA
FIXITY TO THE SKIN SHOULD TEST WHETHER SKIN OVER THE SWELLING PINCHABLE OR NOT SEBACEOUS CYST, PAPILLOMA,EPITHELIOMA ARISE FROM SKIN THEY MOVE WITH SKIN IN MALIGNANT SELLINGS IF SKIN IS INFILTRATED SKIN IS NOT PINCHABLE
SEBACEOUS CYST, ARISE FROMSKIN THEY MOVE WITH SKIN
PLANE OF THE SWELLING SKIN---SKIN IS NOT MOVED OVER THE SWELLING SUBCUTANEOU TISSUE----the tumors arising from subcutaneous are free from both skin and underlying contracted muscle.SKIN IS PINCHABLE&SWELLING PROMINENT WHEN MUSCLE IS contracted & MOVES freely over contracted muscle Swellings arising from the deep fascia are not as mobile as those arising from the sub cutaneous tissue.but it is very difficult to find out whether the tumor is fixed to deep fascia or not as the fascia can not be made taught separately from muscle.
When the tumor arises from sub cutaneous tissue and fixed to muscle, the tumor will be more prominent and cannot be moved along the fibres of muscle when the muscle is contracted. If the tumor incorporated in the muscle, it will be fixed and decreases in size when the muscle is contracted. If the tumor lies deep to muscle, it virtually disappears as soon as muscle become taught Some times swelling appears when the muscle is taught. this is due to tear in the tendon concerned.
Swellings in connection with the tendon of muscle moves along with the tendon and become fixed when the muscle is made taught against resistance. Swelling in connection with the vessels and nerves dont move along the line of the said vessel , the but moves a little extent at right angles to their axes Swellings arising from bone or absolutely fixed even when the muscle is relaxed and cannot be moved apart from bone.
Secondary changes to the swelling-----seen in malignant swellings,tuberculous lymph nodal mass REGIONAL LYMPH NODES—no examination is complete with out the examination of draining lymph nodes. When regional lymph nodes are enlarged it is good practice to examine other group of lymph nodes. to exclude generalized lymphadenopathy.- PERCUSSION :the importace of this examination is not that much important in swelling. its sole place is to find out the presence of resonant note on percussion over hernia. or to elicit tender ness in brodies abscess.
Auscultation: all pulsatile swellings should be Auscultated.machinary murmer is heard in an aneurysmal varix.Movements: joints nearby swelling should be examined for movements to find out whether the joint is involvedd or not.Examine for pressure effects: 1)the arterial pulse distal to swelling some times swelling may press upon main artery of the limb and cause weak pulse distally.2)the nerves may be effected by the pressure of swelling, this cause wasting of muscle,paresis,paralysis.3)swelling may exert pressure on bone eroding it as in aneurysm,dermoidcyst.
General examination in malignantswellings Examine the chest for consolidation, pleural effusion Liver for secondaries General examination of abdomen to find out peritoneal metastases The spine,pelvis,the trochanters of femurs,skull to exclude metastases If one group of lymph nodes are enlarged examine other group of lymph nodes If swelling is suspected of gumma or condyloma, examine for other syphilitic stigmata
REGIONAL LYMPH NODES TB breast with Secondary suppurative Axillary L.nodes