Examination of Swelling ( Lumps and Bumps )

Video: Complete tutorial on Examination of Lumps and Bumps

Inspection ( 6s )

Site

Size ( estimate the dimensions first, say you will confirm it with measurement )

Shape 

Surface ( smooth / irregular )

Skin changes ( Ulceration / pigmentation )

Scars

Site related ( eg. if present at the back of a patient, ask patient to push the wall )

Palpation

Size ( measured with tailor tape in # x # dimensions )

Temperature

Tenderness

Margin / edge. Edge of swelling examined using PULP of INDEX FINGER. Check for erosion of the margin into deeper structures like bone ( eg. dermoid cyst ). In lipoma u have slip sign ( edge slips away as u palpate ). Margin can be well defined or poorly / regular or irregular / sharp or rounded

Image: Slip sign. 

Surface ( with palmar aspect of fingers - smooth, nodular, irregular  )

Consistency ( hard, firm, soft )

Reducibility ( When swelling is pressed gets reduced completely and disappears is said to be reducible swelling  ) 

Compressibility ( Swelling on pressure reduces in size only partially but will not disappear completely and on releasing the pressure swelling again comes back to its original size and shape immediately. 

Pulsations ( thrills , bruits ) - Two fingers placed over swelling

Fluctuation ( confirms presence of fluid )

Fixation to skin - Mobility of the skin over the swelling is checked or skin over the swelling is pinched to confirm whether skin is free or attached to swelling underneath 

Fixity to deeper structures - 

o If swelling is freely mobile it could be in subcutaneous plane 

o If swelling is adherent to muscle underneath, then when muscle is contracted against resistance mobility of the swelling is restricted but it becomes more prominent. When muscles relaxes swelling will be mobile 

o If swelling is arising from the muscle or deep to muscle then size of the swelling decreases (less prominent) when muscle is contracted. Again mobility which is present initially will disappear completely during contraction of the muscle 

Transillumination

Auscultation ( done if pulsatile to look for bruit )

Lymph node examination 

If cervical region, cervical LN

If back, axillary LN

If abdomen, inguinal LN

Discussion:

Possible differentials:

Lipoma

Sebaceous cyst ( will have punctum in middle )

Hemangioma 

Abscess

Soft tissue tumour

Bone tumour ( eg. multiple osteochondroma )

Vascular malformation

Lymphangioma

Neurofibromatosis

Dermoid cyst

What is a lipoma?

Benign tumour of fat

Most common soft tissue tumour of adulthood

Dercum’s disease = multiple lipomas

Dangerous lipomas

Intestinal mucosa lipoma ( can cause obstruction ) 

Vocal cord ( respiratory distress )

Thecal or spinal cord ( paralysis )

Where can you not find lipomas 

Palm

Sole

Brain

Tongue

Investigations

Clinical examination

Ultrasound

CT / MRI

Biopsy ( excisional )

Management:

Excision

Liposuction for lipoma

Video: Lump and Bump examination, with mannequin.