History of swellings
•Site
•Onset (noticed – pain or others)
•Duration
•Associated symptoms
•Progress
•Disappearance/appearance
•Any other swellings
•Affect function
Examination of swellings
•Inspection
•Palpation
•Percussion
•Auscultation
Inspection
•Site and
numbers
Inspection
•Size
Inspection
•Shape
•Surface
Inspection
•Skin
Inspection
 Visible pulsation
 Visible cough impulse
(connected to cavity
like chest, abdomen,
spinal canal and
cranium)
 Pressure effects
Palpation
•Important note:
•Be gentle
•Don’t hurt the patient
•Methodical (do examination in
order)
Palpation
 Tenderness
 Temperature
 Thrills
If the swelling is not acutely tender, you can
proceed to finish your examination
 Size by using measuring tape (vertical,
horizontal and depth)
Palpation
•Surface
•Edges:
•Well-defined and regular (benign)
•Well-defined and irregular (malignant)
•Ill-defined and diffuse (inflammatory)
Palpation
Consistency:
•Very soft (like jelly – cystic)
•Soft (relaxed muscle)
•Firm (contracted muscle, nasal cartilage)
•Hard (contracted biceps of boxer)
•Stony hard
•Variable consistency
Palpation
Consistency: cont……..
 Fluctuation test for cystic swelling
 Pascal’s law (pressure exerted to a fluid is transmitted equally in
all the directions)
Fluctuation
Cross fluctuation
Palpation
Consistency: cont…….
 Pseudo fluctuation: as in large soft swelling
such as lipoma (failure of transmission in all
direction)
 Indentation: press the swelling for 1 min, if
swelling indented (contains pultaceous
material) as in sebaceous cyst
Palpation
•Cough impulse: tense or increase in size
•Transillumination: transmission of light
through a swelling (thin wall and clear
fluid)
Palpation
• Transillumination
• Congenital hydrocele
Palpation
• Transillumination
• Cystic hygroma
Palpation
 Reducibility: hernia
 Compressibility: vascular hemangioma
 Pulsation:
◦ Expansile pulsation as in aortic aneurysm
◦ Transmitted pulsation as in stomach mass near the
aorta (eliminated by elbow-knee position)
 Skin over the swelling (free or fixed)
Palpation
Relation to surrounding tissues and
fixity:
◦Subcutaneous, muscle, deep to muscle,
bones
Palpate for regional lymph nodes
Percussion
•Of limited value
•Tympanic in pharyngocele
•Useful in evaluating the retrosternal
extension of goiter
Auscultation
•Bruit: medium pitched murmur heard over
the swelling with each pulse wave.
•Heard in:
• Aortic aneurysm
• Toxic goiter
• Malignant vascular tumors
Pressure effects
Goiter
Swelling may press on:
◦Artery: feel peripheral pulses
◦Veins: edema
◦Nerves: paresthesia and muscle wasting
◦Near joints: affect their movement
What is the cause of the swelling?
•Congenital
•Acquired:
• Inflammatory
• Traumatic
•Neoplastic
•Others: autoimmune, allergic
Swellings with special signs
Sebaceous cyst:
◦ Retention cyst
containing sebum
◦ Common in places
where there are
◦ Has punctum
◦ Skin attached
◦ Smooth surface
◦ Indented
◦ Cock’s peculiar tumor
sebaceous glands
(sebaceous cyst linked
(common in face,
growth – hair follicle -
scalp, scrotum, ..)
◦ Rounded
proliferating
trichilemmal cyst)
Swellings with special signs
Lipoma:
◦ Subcutaneous lipoma:
◦ Not tender
◦ Soft
◦ Lobulated
◦ Overlying skin is free
◦ Well-defined edges
◦ Slipping sign is a characteristic
◦ Freely mobile
•Multiple lipomatosis called Dercum’s disease
Swellings with special signs
•Goiter:
• Moves with swallowing
• Solitary or diffuse or multinodular
• Bruit may be heard in toxic goiter
• May have retrosternal extension (can not go below
it, trachea not felt, percussion)
• Vocal cords should be examined
• Associated signs as in toxic goiter
Swellings with special signs
•Breast cancer:
• Peu d’orange
• Retraction of the nipple
• Tethering of the skin
• Ulceration and fungation
• Fixation
• Lymph nodes
Swellings with special signs
Cystic hygroma:
◦ Site: root of the neck, axilla, groins, mediastenum and
tongue
◦ Congenital malformation affecting lymphatic channels
◦ Contains clear lymph
◦ Cystic
◦ Ill-defined edges
◦ Positive translumination
◦ Increases with crying
Swellings with special signs
• Malignant melanoma of the foot
Swellings with special signs
• Neurofibromatosis (Recklinghausen’s disease)
Swellings with special signs
•Hernias
Swellings with special signs
 Keloid
 Keloid
Swellings with special signs
Thyroglossal cyst -- External angular dermoid cyst
Swellings with special signs
Meningocele