EXAMINATION

OF
SWELLING
1. Muhammad Danial
2. Farhan Ali
3. Nur Syafiqah
OUTLINE OF PRESENTATION
DEFINITION
HISTORY
INSPECTION
PALPATION
SPECIAL TEST
PERCUSSION
AUSCULTATION
END OF EXAMINATION
DIFFERENTIAL DIAGNOSIS
 Definition OF
SWELLING

Transient abnormal enlargement of a body part or area

not due to cell proliferation.
An eminence or elevation

Source: Dorland’s Pocket Medical Dictionary

 HISTORY
Duration: How long is the swelling present?
Site: Where was the swelling first noticed?
Mode of onset: Whether swelling appeared following trauma, or developed spontaneously.
Progress of swelling:
-Static: Same as onset, no increase in size
-Slowly increasing in size since the beginning (usually benign swelling)
-Rapidly increasing in size since beginning (usually malignant)
-Initially slowly increasing in size, later (after a variable period) started rapidly increasing in size
(benign swelling showing malignant change)
-Initially increasing size. Later the swelling regressed with time or treatment (inflammatory)
-Ask the patient what was the size of the swelling when he/she first noticed it.
 Pain over the swelling:
-Duration of pain
-Site of pain
-Character of pain
-Any radiation of pain e. Periodicity of pain
-Relation of pain with the swelling

Any other swelling in the body

Any history of fever, loss of appetite, loss of weight
Any subsequent changes over the swelling, e.g.ulceration. Ask when these changes
were first noticed
In a suspected malignant disease enquire about symptoms that will suggest metastasis,
chest pain, cough, hemoptysis, bone pain, headache, vomiting, loss of consciousness,
convulsion, pain abdomen, abdominal distension, and jaundice
Any history of previous excision of the swelling and recurrence
History of similar swelling in the past

Past History/Personal History/Family History/Treatment History/History of Allergy

 EXAMINATION
Wash hands
Introduce yourself
Permission (Explain procedure)
Position
Ensure patient is comfortable
Exposure: Expose area to be examine only
INSPECTION
 PALPATION
Temperature - warm, cold, body temperature
Tenderness - watch the patient’s face
Size - measure width or length in cm
(vertical &horizontal diameters better
clarified by palpation)
Surface - smooth, rough, irregular
Margin - well-defined & regular ( benign neoplasms )
- well-defined & irregular ( malignant neoplasms )
- Ill defined & diffuse ( inflammatory swelling )
Consistency - soft, firm, stony hard ( carcinoma ) bony hard ( osteoma )
Mobility - mobile in only certain direction, fixed, immobile
Relations to surrounding tissue - inflammed
Compressibility - pitting on pressure, no changes

Reference: Bedside Clinics in Surgery 2nd edition

SPECIAL TESTS
PERCUSSION
AUSCULTATION
 sPECIAL TESTS
There are a few special tests that can be carried out to confirm swelling:
1) Pulsation
2) Fluctuation
3) Transillumination
4) Cough Impulse
5) Reducibility
6) Compressibility
7) Slippage Sign
 Pulsation
Pulsation is elicited by placing your hands on each side of the swelling, so that
your index fingers are gently resting on each side of the swelling. Then, note if
the mass feels pulsatile.

This test is usually done when the swelling/lump is located near arteries or
vascular in origin.

If the swelling is pulsatile, it may suggest an aneurysm or vascular tumors. An

aneurysm can rupture if the examination is too rigorous.

If the mass is pulsatile, stop examining and ask a medical officer/specialist to

review the patient
 True Pulsation versus False Pulsation
True Pulsation: occurs upward, downward and outward
False Pulsation: occurs only up and down; the mass sits on top of the artery,
but does not distend outwards

True

False
 Expansile
pulsation

Transmitted
pulsation
 Fluctuation
Two digits (fingers) are placed either side of the apex of the
swelling. Using a finger, pressure is applied to the apex. Then,
repeat with the digits at 90 degrees to the previous position.

The test result is positive if the two fingers are pushed away
in both
directions in both positions.

If the swelling is fluctuant, it suggests the presence of fluid

within the swelling.
 Transillumination
Transillumination is done by shining a bright pinpoint light source against one
side of the swelling (do not shine on top of it). Procedure should be carried
out in a darkened room.

A positive result indicates clear fluid (water, serum, lymph) and also thin,
transparent walls. A negative result indicates presence of opaque fluids such
as blood. Light can be transmitted through transparent fluids but not opaque
fluids.

Light seen emerging from the other side is termed as ‘transillumination’.

Transillumination confirms lumps/swelling that contain fluid.
Principle: The light is transmitted through the
transparent fluid

Diagnosis of hydrocephalus by cranial

transillumination

Transillumination of lump on finger

 Cough Impulse
Swelling is held with fingers and patient is asked to cough.

If the swelling becomes tense or increases in size, the cough impulse test is
positive, and vice versa.

Swellings with cough impulse are:

Hernia
Lumbar abscess
Spinal/Cranial meningocele
 Reducibility
Patient is asked to relax, and the swelling is compressed from all the sides
uniformly.

Reducible swellings will either decrease in size or completely disappear.

A reducible swelling once reduced; disappears. It reappears only by straining,

coughing, (or force of gravity as it involves displacement of viscera to
adjoining cavity)

Indication is the same as for cough impulse.

 Compressibility
When pressure is applied to a swelling, it decreases the swelling but when
pressure is released, the swelling returns to its original size without the
influence of any external factor

A compressible swelling is usually indicative of vascular malformations or

fluid collections

Compressibility is a characteristic sign of vascular hemangioma.

 Slippage Sign

Done to differentiate lipoma and cystic swelling as both has well-defined

margin and regular border. The edge of the swelling is palpated with one
finger. In lipoma, the tumor will slip away from the finger on gentle pressure;
and the opposite is true for cystic swelling
 percussion & AUSCULTATIOn
Percussion is done to confirm the size and the borders of the mass.

Solid and fluid filled lumps will be dull upon percussion; and gas-filled
lumps will be resonant upon percussion.

Typical findings on auscultation include bruits/murmurs (suggestive of

vascular etiology - arteriovenous fistula)

Listen for bowel sounds and if present, it suggests hernia

 end of examination
Complete the examination of swelling with:

Regional lymph node examination

Doing a complete general examination
Examine other swellings on the body, if present
Differential diagnosis
 1. scc (malignant Neoplastic)

Features

Inspection Site Any part of skin, commonly neck, hands, forearms

Size, shape, Starts as small nodules but eventually enlarge to become circular nodules with prominent
colour everted edges; dark red

Palpation Surface Rough, scaly, fungating, ulcerated surface and flat reddish patches

Consistency Firm

Fluctuation May show fluctuation

Transilluminate Non-transilluminate
1. scc (malignant Neoplastic)
Tenderness Non-tender

Fluid thrills No

Reducibility No

Fixation Not attach to the skin

Mobility Mobile in early cases, fixed in late cases

 1. Bcc (malignant Neoplastic)

Features

Inspection Site Sun-exposed skin

Size, shape,
Starts as small nodules but eventually enlarge to become circular nodules; pinkish
colour

Palpation Surface Nodular

Consistency Firm and solid

Fluctuation May show fluctuation

Transilluminate Non-transilluminate
1. Bcc (malignant Neoplastic)
Tenderness Non-tender

Fluid thrills No

Reducibility No

Fixation Not attach to the skin

Mobility Mobile in all direction

 2. LIPOMA (BENIGN Neoplastic)
A cluster of fat cells which have become over-active and so distended with fat that they become palpaple lumps.
Occur at all ages, but not common in children

Features

Subcutaneous tissues of the upper limbs, chest, neck and shoulders, but they can
Inspection Site
occur anywhere

Size & shape Usually spherical, but subcutaneous lipoma usually discoid or hemispherical.

Palpation Surface non-tender, Soft/ firm, well-lined edge, ”slip sign”

Consistency Smooth / lobulated surface on firm pressure

Fluctuation May show fluctuation

Transilluminate non-transilluminate
 2. LIPOMA (BENIGN Neoplastic)
Features

Fluid thrills No fluid thrills

Reducibility Not reducible

Fixation Not attach to the skin

Mobility Mobile in all direction

A lipoma in the subcutaneous tissues of

the upper arm.
Note the lobulation

A large lipoma overlying the scapula

Source: Browse’s Introduction to symptoms & signs of surgical

diseaae, 4th edition, page 79
 3. Dermoid cyst
Features Congenital Acquired

Develop when a piece of skin survives after

Noticed at birth but it usually becomes
being forcibly implanted into the subcutaneous
History obvious a few years later when it begins
tissue by an injury (often a small, deep cut or
to distend.
stab)

Inspection Site head, neck, trunk Beneath skin liable to be injured

0.5 - 1.0 cm in diameter, spherical, smooth and

Size & shape 1-2 cm in diameter, ovoid or spherical
small

Palpation Surface Not warm, smooth surface, well margin

Consistency soft, not tense and hard hard, tense and sometimes stony hard

Fluctuation Positive usually not fluctuate

 3. Dermoid cyst
Features Congenital Acquired

Only if it contain clear fluid instead of the

Transillumination usual thick, opaque mixture of sebum, sweat
and desquamated epithelial cells.

Fluid thrills For large cyst usually no fluid thrills

Congenital dermoid cyst Acquired dermoid cyst

Source: Browse’s Introduction to symptoms & signs of surgical
diseaae, 4th edition, page 79
 4. INFLAMMATIONS
Furuncles (Boil) Carbuncle Cellulitis

Caused by infection entering

a hair follicle
The infection first produces
pus and then a central core of
necrotic tissue.
Staphylococcus aureus
Acute spreading infection of the
Furuncles grouped together.
skin that may extends deeper
Larger, consists of honeycomb of
than the skin and involves tissue
abscesses, often draining via
Group A streptococcus, S. aureus,
multiple sinuses.
H. influenza, Vibrio vulnificus.

Face, neck, axillae, groins and

Face, neck, axillae, groins and
buttocks Oedema of the reddened skin
buttocks
Inspection Red with indurated edge with gives the involved area a raised
Red, raised, pus-containing
necrotic slough and pus in the border.
swelling
centre.

Tender Tender
Tender
Hot swelling Warm on palpation
Hot
Palpation Not mobile Not mobile
Erythema that blanches when
Firm at first, then become Centre is soft and surrounding
palpate
fluctuant tissue is indurated and firm
 4. INFLAMMATIONS

Furuncles

source :
https://www.msdmanuals.com/professional/dermatologic
-disorders/bacterial-skin-infections/furuncles-and- source :
carbuncles Essential Surgery : problems, diagnosis, management, 5th edition. page 574 & 576
 5. GANGLION cyst
Features A cystic, myxomatous degeneration of fibrous tissue.

Inspection Site Found near joint capsules and tendon sheats, commonly around wrist, on dorsum and ankle

Size & shape Variable. Small ganglia: 0.5 - 1.0 cm, tense and spherical. Large ganglia: 5-6cm, flattened and soft.

Palpation Surface Smooth surface

Margin Clearly defined

Consistency Large: soft, Small: Firm

Fixation Not fixed to the skin, freely mobile over them.

Fluctuation Positive if large

Transillumin
Transilluminate brightly
ation

Reducibility Compressible but not reducible

 5. GANGLION cyst

A soft multilocular gangliion on the back of the wrist A small, tense ganglion on the back of the wrist which was
only cleared visible and palpable when the wrist was
flexed.

Source: Browse’s Introduction to symptoms & signs of surgical

disease, 4th edition, page 80
 6. Sebaceous cyst
Formed due to obstruction of the draining duct of a sebaceous gland.

Features

Inspection Site Anywhere except palm and soles

Size & shape varies from a few milimetres to 4-5cm in diameter, spherical

usually normal but when infected may cause redden skin tender/ increase temperature
Skin
on palpation

Asscociated Punctum where a foul-smelling cheesy exudates (sebum) can be squeeze out, sebaceous
symptoms horn
 6. Sebaceous cyst
Features

Palpation Surface Smooth

Edge well-defined margin

Consistency Soft/ firm

Fixation Fixed to skin

Flunctuation Negative

Transillumination Not transilluminate (full of sebum)

Compressibility Not compressible

Reducibility Not reducible

Indentition Positive
 6. Sebaceous cyst

Three sebaceous cysts on the scalp.

A sebaceous horn on the ear.

A small sebaceous cyst on the skin. The ‘horn’ is simply the hardened sebaceous
The slight erythema is the residue of a recentinfection material extruding from the cyst
in the cyst,

Source: Browse’s Introduction to symptoms & signs of surgical

disease, 4th edition, page 73
 References
1. Browser's introduction to the symptoms and signs of surgical disease
2. Talley and O’ 'Connor's Clinical Examination
3. Bedside Clinics in Surgery 2nd edition
4. Bailey and Love, Principle and Practise of Surgery 25th Edition
5. Dorland’s Pocket Medical Dictionary, 28th Edition.
Thank you