Most of us come across this particular sign quite often. Of course, you can just jump to the numerous investigations and one after another, rule out the possible causes, finally getting to the diagnosis. For me, that’s no fun at all. Although I still don’t know whether I am going to become a surgeon or not (embarassing for me, since I’m going to be done with med-school this year), its pretty fascinating. If I were to work in a country whether investigations aren’t that expensive, I would definitely just perform a small examination and take a short history, sending off my patient to get a myriad of investigations, reporting to me after a while, with the diagnosis in his reports. However, things won’t be that easy for me for a while (since I’m living in a third world country where investigations and routine lab tests are not affordable by the common man, unless direly and urgently required), I will definitely resort to honing my own examination and history taking skills. I must admit, it’s much more fun this way. (Literally makes me feel like I’m Sherlock Holmes )
Enough with the blabbing, here’s how I would examine a swelling if a patient presented with one:
1. Proper exposure of the site.
- Site- Exact location should be found out by measuring the distance from the nearest bony landmark and describing the site in anatomical terms (for example, there’s a circular swelling on the extensor surface of the right forearm, 5 cm from the elbow joint or the wrist joint, etc).
- Overlying Skin: Texture (smooth, rough,scaly, dry, discoloured, depigmented, hyperpigmented, etc).
- Ask the patient if the swelling is acutely tender. If not, proceed towards examination and keep an eye on the facial expressions of your patient to see whether he or she is in pain.
- Measure the exact size of the swelling.
- Feel the surface of the swelling.
- Feel the edges and decipher whether they are sharp or blunt, smooth or rough or nodular, well defined or diffuse, etc.
- Ascertain whether it is attached to the skin, underlying muscles, or deeper structures. A swelling that is attached to the skin will not the overlying skin to be pinched, if it is attached to a structure below the superficial muscle, it will disappear or fade slightly when you ask the patient to perform a movement which causes that muscle to contract (for example,swellings attached to the peritoneum will fade when the abdominal muscles are tense which can be done by telling the patient lie down without a pillow and extend his or her legs, keep the knees stiff and raise the feet from the bed).If the swelling does not disappear, it is attached to the muscle or skin.If it is attached to the muscle, it will be freely moveable when the muscle contracts and its range of movement will decrease when the muscle is contracted, but it will not disappear.
- Consistency (Hard: like the upper part of your nose, firm: the lower part of your nose, soft: similar to what your earlobe feels like)
- Fluctuation – If application of pressure on one side of the swelling makes another side protrude, that means the swelling is fluctuant and probably contains fluid in it.
- Fluid Thrill – Place your index finger on either side of the swelling, tapping one side gently and pressing the other finger’s tip slightly firmly to feel the thrill. If present, it also indicates the presence of fluid.
- Trans-illumination – Press the tip of a lighted pen torch and if the swelling transmits light, it contains fluid and the test is positive.
- Pulsation – First, place the pulps of your fingers (the number of fingers depend on the size of the swelling) for about 5 seconds to feel if there are any pulsations. If present, put the index fingers on either side of the swelling, if your fingers are raised upwards the pulsations are transmitted from a nearby artery and if they are pushed apart, they are due to true pulsations from within the swelling (usually due to the swelling being an underlying aneurysm).
- Compression – Check if the swelling can be compressed by pressing it. If it refills after your release the pressure, it is compressible. Venous malformations are usually the cause since their low pressure causes the blood to go back and pressure release causes re-filling.
- Reducibility – This is not the same as compressibility. If the lump or swelling does not re-appear after you push it inwards, it is reducible and will only return when a force is applied in the opposite direction of the initially applied pressure. This is common in hernias when pressure on them reduces them and coughing makes them bulge out again.
- Indentation – Check whether the swelling gets ‘dented’ when you apply pressure.
Although not to be done in fluctuant swellings, it can carried to rule out the presence of air in a swelling since that area would sound resonant as compared to the surroundings.
Listen for bruits, venous hums, etc. Vascular swellings will have systolic bruits (such as aneurysms), arterio-venous malformations will have a continuous bruit heard throughout diastole and systole whereas hernias which contain gut loops might let you hear bowel sounds.
6.Local Lymph Nodes:
In cases of acutely tender and inflamed swellings, local lymph nodes might be swollen (pointing towards an infection) so the local lymph nodes should always be assessed.
7.Examine the whole body for any other swellings, whether similar or not.
8.State of the local tissues – are they inflamed, is their abdominal guarding (if the swelling is in that region), etc.
9.NEVER EVER forget to do a general physical exam of the patient since that gives an overview of the patient’s health and can aid you in reaching the diagnosis.