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EXAMINATION OFSWELLING          DR.K.SUGUNAKAR
HISTORY   how long is the lump present?   when was the lump first noticed?   There is a heaven and hell difference    b...
   SHORTDURATION&PAIN: INFLAMMATORY   SINCE BIRRTH:CONGENITAL   LONGER DURATIONWITH OUT PAIN :BENIGN   LONGER DURATION...
What is your diagnosis?
What is your diagnosis?    DURATION: SINCE BIRRTH:CONGENITAL
MODEOF ONSET   HAVE APPEARED AFTER TRAUMA ;fractured displacement    of bone,dislocation of joint,haematoma   DEVELOPED ...
OTHER SYMPTOMS   PAIN----inflammatory or involving nerves   DIFFICULTY IN RESPIRATION---pressure on trachea   DIFFICULT...
pain   Nature of pain: throbbing pain suggests inflammation    leading to suppuration.pain may be burning,stabbing,aching...
PROGRESS OF THE SWELLING   GROWING SLOWLY-------benign swellings   GROWING QUICKLY--------malignant swellings   SUDDENL...
   EXACT SITE: site of the swelling tells from    which organ the swelling was originated.   PSENCEOF OTHER LUMPS:    ne...
   PSENCE OF OTHER LUMPS:    neurofibromatosis,diaphysial    aclasia,hodgkins lymphoma may present    with multiple swell...
What is your diagnosis?
   EXACT SITE: site of the swelling tells from    which organ the swelling was originated.
SUB MANDIBULAR REGION                SUB MANDIBULAR GLAND                LYMPH NODE                PLUNGING RANULA
   Swelling present since    birth   Neck swelling in    posterior and anterior    triangle of neck   Cystic swelling
Swelling present since birthNeck swelling in posterior andanterior triangle of neckCystic swelling
DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
Thyroid swelling—moving upward withdigglutition
   SECONDARY CHANGES LIKE    SOFTENING,ULCERATION,FUNGATION,IN    FLAMMATORY CHANGES----malignant    swellings &T.B.lymph...
SECONDARY CHANGES---------------------------------------------------------- FUNGATION
SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION
SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION
   RECURRENT SWELLINGS---malignant    swellings, malignant growth in benign    swellings.certain swellings like pagets   ...
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—a...
   PAST HISTORY; important in tuberculosis   FAMILY HISTORY: important in carcinoma breast,medullary    carcinoma thyroi...
LOCAL EXAMINATION   SITE OF THE SWELLING: a few swellings are peculiar in their    positions such as dermoid cyst are mos...
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 nev...
   SURFACE: in certain swellings suface may    be very much obvious and diagnostic.    cauliflower surface of squamous ce...
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  ...
MULTIPLE SWELLINGS-------------------------------------------NEUROFIBROMATOSIS
MULTIPLE SWELLINGS-         Sebaceous cysts
Lipoma- nape of the neck –mostcommon site- solitary swelling
DERMOID---solitary swelling
BLUE COLOURED SWELLING IN THEFLOOR OF THE MOUTH------RANULA
Redness,oedema,&pain---inflammatoryswellings
   PULSATION: swellings arising from the arteries are    pulsatile,eg.aneurysm and vasculargrowth such as carotid body   ...
Redness,oedema,&pain---inflammatoryswellings
Skin------tense,glossy with venousprominence in sarcoma with rapidgrowth                  
Sebaceous cysts----------skin is notpinchable,cystic swelling withpunctum
Scar---previous surgery
PALPATION   LOCAL RISE OF    TEMPERATURE:   DUE TO INCREASED    VASCULARITY   MAYBE    INFLAMMATORYOR    VASCLAR TUMOR ...
TENDERNESS   GENTLE PRESSURE    OVER SWELLING   SHOULD SEE THE FACIAL    EXPRESSION   INFLAMMATORYSWELLIN    GS ARE TEN...
   SIZE ,SHAPE ,EXTENT CAN BE CLEALRY KNOWN WITH    PALPATION   IT IS BETTER TO MENTION IN VERTCAL AND HORIZONTAL    DIA...
SURFACE   SMOOTH      CYSTIC   NODULAR     LYMPHNODAL MASS   LOBULAR     LIPOMA   IRREGULAR   MALIGNANT
SMOOTH SURFACE
NODULAR SURFACE
EDGE   WELLDEFFINED   NEOPLSTIC,CHR.INFL   SMOOTH         BENIGN   IRREGULAR      MALIGNANT   ILLDEFINED     ACUTE    ...
SLIP SIGN   BOTH LIPOMA AND CYST    HAVE SMOOTH    MARGINNS   LIPOMA SLIPS AWAY ON    PALPATION   CYST YIELDS ON    PAL...
CONSISTANCY   IT DEPENDS ON WHAT IT IS MADE UP OF   CYSTIC   FIRM   HARD   UNIFORM IN COSISTACY OR VARIABLE IN CONSIS...
FLUCTUATION   SWELLING FLUCTUATES WHEN IT HAS FLUID   FIRST TO FIX THE SWELLING   THIS TEST SHOULD BE PERFORMED IN TWO ...
TRANSLUSENCY   THIS MEANS SWELLING    TRASMITS LIGHT WHEN IT    HAS CLEAR FLUID LIKE    WATER,LYMPH,SERUM,PL    ASMA   N...
IMPULSE ON COUGHING   SWELINGS WHICH HAVE CONTINUITY WITH ABDOMINAL    CAVITY-HERNIA   SWELLINGS WHICH HAVE CONTINUITY W...
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 swe...
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 PRES...
HAEMANGIOMA
PULSATILITY   ARISING FROM ARTERY--EXPANSILE PULSATION-    ANEURISM   VERY CLOSE TO ARTEY---TRANSMITTED PULSATION   SWE...
   FIXITY TO THE SKIN   SHOULD TEST WHETHER SKIN OVER THE SWELLING    PINCHABLE OR NOT   SEBACEOUS CYST, PAPILLOMA,EPIT...
SEBACEOUS CYST, ARISE FROMSKIN THEY MOVE WITH SKIN
   PAPILLOMA, ARISE FROM SKIN   MOVE WITH SKIN
PLANE OF THE SWELLING   SKIN---SKIN IS NOT MOVED OVER THE SWELLING   SUBCUTANEOU TISSUE----the tumors arising from    su...
   When the tumor arises from sub cutaneous tissue and fixed to    muscle, the tumor will be more prominent and cannot be...
   Swellings in connection with the tendon of muscle moves along    with the tendon and become fixed when the muscle is m...
   Secondary changes to the swelling-----seen in malignant    swellings,tuberculous lymph nodal mass   REGIONAL LYMPH NO...
Auscultation: all pulsatile swellings should be  Auscultated.machinary murmer is heard in an aneurysmal varix.Movements: j...
General examination in malignantswellings   Examine the chest for consolidation, pleural effusion   Liver for secondarie...
REGIONAL LYMPH NODES   TB breast with    Secondary suppurative    Axillary L.nodes
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
Examination of swelling
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Examination of swelling

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Examination of swelling

  1. 1. EXAMINATION OFSWELLING DR.K.SUGUNAKAR
  2. 2. 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.
  3. 3.  SHORTDURATION&PAIN: INFLAMMATORY SINCE BIRRTH:CONGENITAL LONGER DURATIONWITH OUT PAIN :BENIGN LONGER DURATION WITH PAIN AND SHORT DURATION- ------------MAYBE MALIGNANT
  4. 4. What is your diagnosis?
  5. 5. What is your diagnosis? DURATION: SINCE BIRRTH:CONGENITAL
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10.  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.
  11. 11.  PSENCE OF OTHER LUMPS: neurofibromatosis,diaphysial aclasia,hodgkins lymphoma may present with multiple swellings.
  12. 12. What is your diagnosis?
  13. 13.  EXACT SITE: site of the swelling tells from which organ the swelling was originated.
  14. 14. SUB MANDIBULAR REGION  SUB MANDIBULAR GLAND  LYMPH NODE  PLUNGING RANULA
  15. 15.  Swelling present since birth Neck swelling in posterior and anterior triangle of neck Cystic swelling
  16. 16. Swelling present since birthNeck swelling in posterior andanterior triangle of neckCystic swelling
  17. 17. DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
  18. 18. Thyroid swelling—moving upward withdigglutition
  19. 19.  SECONDARY CHANGES LIKE SOFTENING,ULCERATION,FUNGATION,IN FLAMMATORY CHANGES----malignant swellings &T.B.lymphadenitis
  20. 20. SECONDARY CHANGES---------------------------------------------------------- FUNGATION
  21. 21. SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION
  22. 22. SECONDARY CHANGES-------------------------------------------------SKIN ULCERATION
  23. 23.  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.
  24. 24. RECURRENT SWELLINGS—parotidadenoma recurred after surgery
  25. 25. Dermato sarcoma protuberance ----------------------------known for recurrence
  26. 26.  LOSS OF BODYWEIGHT-- malignant&tuberculosis LOSS OF APPETITE-- malignant&tuberculosis - HISTORY OF FEVER—acute& chronic, inflammatory swellings, malignant swellings, lymphomas
  27. 27.  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
  28. 28. 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
  29. 29. DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
  30. 30. DERMOID AT THE FUSION OFSUTURE LINES-outer canthus of eye
  31. 31.  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
  32. 32.  SURFACE: in certain swellings suface may be very much obvious and diagnostic. cauliflower surface of squamous cell carcinoma, irregular numerous branched surface of papilloma.
  33. 33. Papilloma from nipple ---------------------------------------------------irregular numerousbranched surface of papilloma.
  34. 34.  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
  35. 35. MULTIPLE SWELLINGS-------------------------------------------NEUROFIBROMATOSIS
  36. 36. MULTIPLE SWELLINGS- Sebaceous cysts
  37. 37. Lipoma- nape of the neck –mostcommon site- solitary swelling
  38. 38. DERMOID---solitary swelling
  39. 39. BLUE COLOURED SWELLING IN THEFLOOR OF THE MOUTH------RANULA
  40. 40. Redness,oedema,&pain---inflammatoryswellings
  41. 41.  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)
  42. 42. Redness,oedema,&pain---inflammatoryswellings
  43. 43. Skin------tense,glossy with venousprominence in sarcoma with rapidgrowth 
  44. 44. Sebaceous cysts----------skin is notpinchable,cystic swelling withpunctum
  45. 45. Scar---previous surgery
  46. 46. PALPATION LOCAL RISE OF TEMPERATURE: DUE TO INCREASED VASCULARITY MAYBE INFLAMMATORYOR VASCLAR TUMOR LIKE SARCOMA
  47. 47. TENDERNESS GENTLE PRESSURE OVER SWELLING SHOULD SEE THE FACIAL EXPRESSION INFLAMMATORYSWELLIN GS ARE TENDER NEOPLSTIC SWELLINGS ARE NON TENDER
  48. 48.  SIZE ,SHAPE ,EXTENT CAN BE CLEALRY KNOWN WITH PALPATION IT IS BETTER TO MENTION IN VERTCAL AND HORIZONTAL DIAMETRES
  49. 49. SURFACE SMOOTH CYSTIC NODULAR LYMPHNODAL MASS LOBULAR LIPOMA IRREGULAR MALIGNANT
  50. 50. SMOOTH SURFACE
  51. 51. NODULAR SURFACE
  52. 52. EDGE WELLDEFFINED NEOPLSTIC,CHR.INFL SMOOTH BENIGN IRREGULAR MALIGNANT ILLDEFINED ACUTE INFFLAMMATORY
  53. 53. SLIP SIGN BOTH LIPOMA AND CYST HAVE SMOOTH MARGINNS LIPOMA SLIPS AWAY ON PALPATION CYST YIELDS ON PALPATION
  54. 54. CONSISTANCY IT DEPENDS ON WHAT IT IS MADE UP OF CYSTIC FIRM HARD UNIFORM IN COSISTACY OR VARIABLE IN CONSISTACY
  55. 55. FLUCTUATION SWELLING FLUCTUATES WHEN IT HAS FLUID FIRST TO FIX THE SWELLING THIS TEST SHOULD BE PERFORMED IN TWO PLANES PAGETS TEST
  56. 56. 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
  57. 57. 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
  58. 58. SWELINGS WHICH HAVE CONTINUITYWITH ABDOMINAL CAVITY-HERNIA
  59. 59. SWELLINGS WHICH HAVECONTINUITY WITH SPINAL CORD-MENINGOCELE
  60. 60. 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
  61. 61. SWELLING REDUCES AND ULTIMATELYDISSAPPEARS AS SOON AS PRESS UP ON  HERNIA
  62. 62. COMPRESSIBILITY THE SWELLING CAN BE COMPRESSED BUT NOT BE DISSAPPEARED COMPLETELY THE SWELLING REAPPEAS WHEN PRESSURE IS TAKEN OFF HAEMANGIOMA,LYMPHANGIOMA
  63. 63. HAEMANGIOMA
  64. 64. PULSATILITY ARISING FROM ARTERY--EXPANSILE PULSATION- ANEURISM VERY CLOSE TO ARTEY---TRANSMITTED PULSATION SWELLING IS HIGHLY VASCULAR----------- TELANGIECTATIC SARCOMA
  65. 65.  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
  66. 66. SEBACEOUS CYST, ARISE FROMSKIN THEY MOVE WITH SKIN
  67. 67.  PAPILLOMA, ARISE FROM SKIN MOVE WITH SKIN
  68. 68. 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.
  69. 69.  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.
  70. 70.  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.
  71. 71.  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.
  72. 72. 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.
  73. 73. 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
  74. 74. REGIONAL LYMPH NODES TB breast with Secondary suppurative Axillary L.nodes

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