The document provides information on examining lumps or swellings, including: - Taking a thorough history regarding duration, mode of onset, pain characteristics, progression, and family history. - Conducting a physical examination including inspection, palpation, percussion, auscultation, and measurements to determine characteristics like size, shape, consistency, mobility, and effects on surrounding structures. - Potential special investigations like blood tests, imaging studies, biopsies, and their types to arrive at a diagnosis and determine if the swelling is benign or malignant. Differential diagnosis may include conditions like dermoid cysts or hemangiomas.

1. EXAMINATION OF A
LUMP OR A
SWELLING

2. Definition
 A ‘Lump’ is a vague mass of body tissue.
 A ‘Swelling’ is a vague term which denotes any enlargement or
protuberance in the body due to any cause.
 A ‘Tumour’ or ‘Neoplasm’ is a growth of new cells which proliferate
independent of the need of the body.

3. HISTORY
Duration:
 shorter duration and pain - inflammatory (acute).
 longer duration and without pain - possibly neoplastic (benign).
 longer duration and with slight pain - chronic inflammatory swellings
 swellings with shorter duration - neoplastic, mostly malignant.
Mode of onset:
 'How did the swelling start’? – spontaneous ,trauma, scar or benign naevus.

4. HISTORY cont…
Pain:
 nature of pain
 site
 Time of onset
Progress of the swelling:
 'Has the lump changed its size since it was first noticed’?
 Increased or decreased in size.

5. HISTORY cont…
 Exact site
 Fever
 Presence of other lumps
 Secondary changes
 Impairment of function
 Recurrence
 Loss of body weight
 Past history
 Personal history
 Family history

6. PHYSICAL EXAMINATION
 General survey: Cachexia or malnutrition, abnormal attitude of limb, raised
temperature and pulse (inflammatory swelling).
LOCAL EXAMINATION
 Inspection
 Palpation
 Regional lymph nodes
 Percussion
 Auscultation
 Measurements
 Movements

7. Inspection
 Situation
 Colour
 Size
 Shape
 Edge
 Surface
 Number
 Pulsation
 Peristalsis
 Movement with respiration
 Movement with deglutition
 Movement with protrusion of
tongue
 Impulse on coughing
 Skin over the swelling
 Any pressure effects

9. Palpation
 Temperature
 Tenderness
 Size, shape, extent
 Surface
 Edge
 Consistency
 Fluctuation
 Fluid thrill
 Translucency
 Impulse on coughing
 Reducibility
 Compressibility
 Pulsatility
 Fixity to the overlying skin.
 Relations to surrounding structures

13. Percussion
 The importance of this examination is not much in case of a swelling.
 Its sole place is to find out the presence of a gaseous content within the
swelling
 e.g. resonant note over a hernia; or to elicit slight tenderness e.g. Brodie's
abscess.

14. AUSCULTATION: All pulsatile swellings should be auscultated to exclude
presence of any bruits or murmurs. 'Machinery murmur' is heard in an
aneurysmal varix.

15. MEASUREMENTS: This is important not only to find out increase in swelling
at definite intervals, but also to find out if there is any wasting distal to the
swelling.
MOVEMENTS: In case of a swelling, the students must not forget to examine
the movements of the nearby joint to exclude any impairment. This should
be noted in the history and is of particular importance to find out if the
swelling has involved the joint or not.

16. EXAMINATION FOR PRESSURE EFFECT:
Swellings will inevitably exert pressure on the surrounding structures. Its effect
effect must be noted by the following examinations :
(i) The arterial pulse distal to the swelling is felt. Sometimes the swelling may
press on the main artery of the limb and causes weak pulse distally.
(ii) The nerves may be affected by the pressure of the swelling. This will cause
wasting, paresis or paralysis of the muscles supplied by the nerve with or
without sensory disturbances.
(iii) The swelling may even exert its pressure on the subjacent bone by
eroding it. This is sometimes seen in aneurysm and dermoid cyst on the skull.

17. GENERAL EXAMINATION:
It is very much tempting while examining a swelling to do all with the
swelling and forget about the rest of the body. This will lead to innumerable
misdiagnoses. So one must examine the patient as a whole.

18. SPECIAL INVESTIGATIONS
 BLOOD: total count (T.C.), differential count (D.C.), haemoglobin (Hb%),
erythrocyte sedimentation rate (E.S.R.) and sugar.
 In urine, estimation of sugar is very important in case of recurrent
abscesses and carbuncles to find out if the patient is suffering from
diabetes.
 Aspiration and examination of the aspirated material physically,
chemically, microscopically and bacteriologically are very important in case
of chronic cystic swellings.

19.  Fine Needle Aspiration Biopsy (FNAB) or Fine Needle Aspiration Cytology
(FNAC).
 X-ray examination is indispensable in case of bony swellings and to find out if
the subjacent bone has been eroded by an aneurysm or a dermoid cyst. Chest
X-ray should be taken when pulmonary metastasis is to be excluded in case of
a malignant growth.
 Skin test.—
(a) Tuberculin test — if positive in infants and young children suggests
tuberculous lesion. If this test is negative in adult, it can straightway exclude
possibility of tuberculous origin of the swelling.
(b) Casoni's test becomes positive in case of a hydatid cyst; but a negative result
cannot exclude hydatid cyst.

20.  Ultrasonography: It is particularly used to determine whether a mass is solid
or cystic.
 Computed Tomography (CT Scan):
- This technique provides unique two-dimensional representation of differing
radiographic densities throughout a cross-sectional volume of tissue.
- It provides more accuracy than that of ultrasonography in assessment of any
growth e.g. its size, shape, local spread and general dissemination. It helps in
exact anatomical localization of deep seated masses even in obese individuals.

21.  Three Dimensional CT Scan (3D CT Scan) — is now available which
provides 3 dimensional picture of the structure or organ of the body.
 MRI
 Angiography
 Biopsy
Biopsy is by far the most important investigation of a swelling

22. Types of biopsy
 a) NEEDLE BIOPSY: In this method a hollow needle is introduced into the swelling
and a core of tissue is taken out for histological examination.
 (b) DRILL BIOPSY — is performed by an apparatus consisting of a small sharp
cannula within which is attached a high speed compressor air drill. This is claimed
to be better than needle biopsy and has been mostly used in case of breast lumps.
The core of tissue obtained by this method is now examined for histopathological
report.
 (c) PUNCH BIOPSY.— This method is more often used in case of tumour for hollow
viscera or solid viscera. With punch biopsy forceps pieces of tissue are taken from
the margin of the tumour along with surrounding normal tissue or from the base
of the tumour.
 (d) OPEN BIOPSY.— This is performed by operation. After getting access to the
tumour a slice of tissue (Incisional biopsy) or the whole of the tumour (excisional
biopsy) is excised and then histopathological examination of the tumour is
performed.
 Incisional biopsy — has the theoretical disadvantage of spreading the tumour to
the adjoining tissues. Excisional biopsy — is safe and better. It is done by excising
the tumour with a margin of healthy surrounding tissue in case of malignant
growth.

23. DIAGNOSIS OF A SWELLING
 While diagnosing a swelling, the clinician should first find out, whether the
particular swelling is originating from — the skin, the subcutaneous tissue,
the muscles, the vessel, the nerve or bone and secondly, the cause of the
swelling —
whether it is:
 congenital,
 traumatic,
 inflammatory,
 neoplastic or otherwise.

24. Characteristics of benign and malignant growths
BENIGN
Symptoms:
 Occurs at younger age.
 1. Duration.— Slow growth.
 2. Pain.— Usually absent.
 3. Loss of weight.— Never seen.
 4. Loss of function.— Usually not seen.
MALIGNANT
 Seen usually above 40 years of age,
but may occur at younger age.
 1. Rapid growth.
 2. May be painful at late stage, barring
osteosarcoma which is painful from
the beginning.
 3.A feature of malignant growth.
 4.Seen quite early.

25. Characteristics of benign and malignant growths
Signs:
 1. Cachexia, anaemia and loss of
weight.— Usually absent.
 2. Mobility.— Freely mobile. 3.
Surface.— Usually smooth.
 4. Margin.— Definite and smooth.
 5. Consistency.— Usually firm6.
Pressure Effects.— Usually absent. 7.
Regional lymph nodes.— Not
enlarged.
 8. Distant metastasis.— Almost never
seen9. Secondary changes.— Not
seen.
 10. Recurrence.— Never recurs after
excision.
 1. Usually present.
 2. Fixed early due to infiltration.
 3. Usually irregular.
 4. Not definite and irregular.
 5. Either hard or of varying consistency.
 6. Often present.
 7. Early involved and enlarged.
 8. A feature of malignant growth — a
late feature.
 9. Often come across.
 10. Often recurs after excision.

26. Histology:
 1. Cell differentiation.— A feature of
benign
 2. Polarity.— Cells are arranged as
parent tissue.
 3. Capsule.— Always encapsulated.
 4. Anaplasia.— Not seen.
 5. Nuclear structure.— Same as the
parent tissue without mitosis..
 1. Cells are usually undifferentiated.
growth.
 2. Polarity is lost
 3. No capsule formation as local
infiltration is the rule.
 4. A feature of malignant growth.
 5. Nucleus becomes larger,
hyperchromatic with mitosis
Characteristics of benign and malignant growths

27. Differential diagnosis
CONGENITAL
1. DERMOID CYST - this cyst may appear anywhere in the midline of the body
as also in places where the two embryonic processes meet each other e.g.
at the outer angle of the
behind the pinna (Fig. 3.9) (Post auricular dermoid), just below the tongue in the
midline (Sub-lingual dermoid) etc.
2. HEMANGIOMA
 These are vascular malformations or hamartomas and may arise from the
capillary or the vein or the artery and accordingly
 called a capillary haemangioma or
 cavernous haemangioma or
 a plexiform (cirsoid) haemangioma respectively