Saturday, November 21, 2009

History taking and examination of a swelling

Some key questions to be asked regarding a swelling (generally)

1. When do you first notice the lump?

REMEMBER, first noticed the lump 3 months ago is not the same as first appeared 3 months ago.

2. How do you notice it?

Below are the 3 commonest answers :

a) It's painful
b) I noticed it accidentally
c) Others told me about it

Generally, if the lump is painful, the commonest aetiology is inflammation.
Most of the patients thought that only painful lumps are cancerous.

3. How does the lump disturbs you?

Basically, the question is asking about the associated symptoms.
It can be pain, discharge, dysphagia, dyspnoea, cosmetically disfiguring, fear of malignancy, etc.

4. Any changes to the lump since you first notice it?

The commonest change is the size.
Whether the lump has increased or decreased in size, or it's size fluctuates.

5. Has the lump ever dissapears before?

Does the lump dissapears when the patient is lying down supine?
or any other activities

6. Do you ever had any other lumps before this?

Asking for multiplicity

7. What do you think is the cause?

Particularly important if there's history of trauma

On examination :

Note the -

a) Position
b) Colour and texture of skin over swelling
c) Size
d) Shape
e) Surface
f) Temperature
g) Tenderness
h) Edge - indistinct/well-defined
i) Composition

Calcified tissues/bone makes the swelling hard
Swelling packed with cells : Firm
Or it might contain fluid (lymph, blood, pus)
Intravascular blood

j) Consistency

Stony hard - not indentable at all, as hard as bone
Firm - hard, but not as hard as bone
Rubbery - slightly indentable, feels like rubber
Spongy - indentable, but with some resillence
Soft - Squashable, no resillence

k) Fluctuation

Palpate the swelling over 3 planes.
Pressure over the 3rd plane of the swelling usually causes the other 2 planes to buldge out or tensed-up
Positive fluctuation test indicates that the swelling might contains fluid

l) Fluid thrill

Only swelling which contains fluid transmits percussion waves.
Use one of the finger to tap one end of the lump, and feel for the vibration produced at another end, using another finger from another hand.
If the swelling is too large, the percussion wave might be transmitted through the wall.
Hence, one should place a hand at the middle of the swelling to prevent such transmission.

m) Transillumination

If the swelling contains clear fluid, it transilluminate.
It should be done using a small bright light source, in a dark room.
Eg, hydrocele, epididymal cyst

n) Pulsatility

Place one finger of each hand over two ends of the swelling.
If both the fingers are moving upwards and outwards -> expansile (eg, aneurysm)
If both the fingers are moving only upwards (one direction) -> transmitted (a lump overlying an artery)

o) Compressibility

As pressure is applied to the swelling, it's compressed.
But once the pressuring hand is removed, the swelling immediately reappears.

p) Bruits
q) Reducibility

This is different from compressibility.
If the swelling is reducible, it is reduced into another space.
As the pressuring hand is removed, the swelling usually takes some time before reappearing, or will only reappear when there's stimulus, eg cough

r) Relation with surrounding tissue

Is it pinchable from the skin?
When the muscle is tensed,
Does it becomes more prominent, less mobile or less prominent and less easily felt?
When the swelling overlies a nerve/or artery -> not mobile along it's course, but mobile across it's length

s) Any palpable regional lymph nodes?
t) General examination