Examination of a Swelling

10/26/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 1

Examination of swellings


Common features

The presentation of lumps, swellings or masses is a common clinical situtation (e.g. breast lump, swollen ankles or a mass found on rectal examination).

Most swellings can be described by a number of common characteristics (e.g. size, shape, position etc). However, there are some characteristics that cannot be described in all cases (e.g. the state and colour of the overlying skin can be described if examining a breast lump, but not if a mass is found in the rectum).

This guide covers the examination of a generic swelling, but please look at the individual study guides for details of specific (rectal, bimanual, breast etc) examinations.

Overview of swelling descriptors

INSPECTION:

Position

Overlying skin

INITIAL PALPATION:

Pulsation

Tenderness

PALPATION:

Mobility

Shape

Surface

Edge

Consistency

Depth

Indentation

Fluctuation

Temperature

Size

Transillumination


Introduction

As always, it is important to introduce yourself and

your status to the patient.

Check the patient‟s identity (name and D.O.B.).

Explain what you plan to do during the examination.

Gain consent for the examination.

Wash your hands using the Ayliffe technique.

Gloves if appropriate (e.g. „internal‟ examinations

such as rectal, or superficial swellings with

evidence of bleeding or infection).


Inspection

A general inspection of the patient (from the

end of the bed) is appropriate (e.g. are they

in pain?)

Ensure adequate exposure of area to be

examined (whilst maintaining dignity).

There are 2 points to note during inspection.

These are Position and the Overlying skin.


Position

Describe the position of the swelling in detail.

For example, „on the anterior aspect of the

left forearm, 10cm distal to the antecubital

fossa‟

Simply writing „on arm‟ would not be

sufficient to distinguish between a swelling

on the left wrist or one on the right shoulder!


Overlying skin

Inspect the overlying skin (if possible).

Is it different in colour to the surrounding

skin? (red, bruised etc?)

Is there pus or blood leaking from the

swelling?

Is the skin broken or intact? (e.g. an insect

bite can have an obvious puncture mark in

the centre)


Palpation

Palpation is the next stage in the

examination of a swelling.

There are 2 aspects of palpation that need to

be assessed carefully first.

This initial palpation includes checking for

Pulsation and Tenderness.


Pulsation

With your hands on each side of the swelling, so that

your index fingers are gently resting on each side of

the swelling, note whether the mass feels pulsatile.

If the swelling is pulsatile, it may suggest an aneursym

(which may rupture if examination is too rigorous).

If a pulsation is felt; does it feel as if the pulsation is in

all directions („true pulsation‟) or simply „up and down‟

(„false pulsation‟)? (see next slide)

If the mass is pulsatile, stop examining and ask a

senior colleague to review the patient.



True versus false pulsation

True pulsation occurs

both up and down and

outwards

False pulsation occurs

only up and down; the

mass sits on top of the

artery, but does not

distend outwards as it

does not transmit the

pressure wave caused by

the flow of blood

X X

Tenderness

Is the swelling tender to touch? If so, extra care

will have to be taken during the examination to

avoid unnecessary discomfort.

The presence or absence of tenderness will

also give you a clue to the cause of the swelling

(e.g. an abscess is usually tender)


Terminology

NOTE:

Do not confuse pain and tenderness.

The patient may have complained of pain

during the history (therefore pain is a

symptom).

Tenderness is a sign that is detected during

examination.


So far…

INSPECTION & INITIAL PALPATION:

So far, we have assessed 4 components of

the swelling.

These are: Position, Overlying skin, Pulsation

and Tenderness

If you need a mnemonic to help you

remember these, then you can use:

Pupils Only Play Tennis


Palpation

Palpate the mass methodically using the pulps of your

fingertips +/- thumb, and ensuring that you examine all

areas of the lump.

From your palpation, you should be able to describe:

Mobility, shape, surface, edge, consistency, depth,

whether you can leave an indentation, whether the

swelling is fluctuant, temperature, size, and whether the

swelling transilluminates.

The order of these elements may depend on the swelling

being examined. However, for most superficial

swellings, the given order would be appropriate.


Mobile or non-mobile

To assess mobility:

Hold the swelling between thumb and index

finger if possible and gently attempt to move

the swelling.

Is the swelling mobile or non-mobile (fixed)?

If mobile, does it move with manipulation or

movement of underlying structures, e.g.

respiration


Shape

Describe the shape of the mass.

Is it spherical? Elliptical? Irregular shape?

Ovoid etc?


Surface

What does the surface of the swelling feel

like?

Rough?

Smooth?

Granular?

Nodular?


Edge

Is the edge defined (can feel it is clearly distinct

from surrounding tissues)? Document as “Clearly

defined edge”.

You may wish to go on to describe the edge further

e.g. “clearly defined edge with nodules present ”

If the edge is not clearly defined, it is termed

„diffuse‟. This means the edge is not clearly

identifiable (e.g. oedema). Document as “Diffuse

edge” or “Edge diffuse”


Consistency

How does the swelling feel when you palpate

it? (we have already described the surface,

but this is the consistency of the entire

swelling)

Is it hard?

Firm?

Soft?

Tense?


Depth

The depth of a swelling depends on cause of the

swelling.

It is documented as either “Superficial swelling” or

“Deep swelling”.

The depth is NOT the measurement of the height of

the swelling.

A rectal mass would be an example of a deep

swelling.

An insect bite on the finger would be an example of

a superficial swelling.


Does the swelling indent?

Apply gentle pressure to the swelling with your index

finger.

Is there a depression left in swelling when pressure

applied is removed? If so, then the „swelling indents‟ or

you are „able to indent swelling‟.

This is characteristic of oedema and faeces.

NOTE: If the swelling indents when you press, but

springs back when your finger is removed, this IS NOT

indentation.

WARNING - do not try to indent a pulsating swelling10/26/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 21


Fluctuant or non-fluctuant

Two digits are placed either side

of the apex of the swelling

Pressure is applied to the apex

This is repeated with the digits at

90°

The finding is positive if the two

digits are pushed away in both

directions

If a swelling is fluctuant, it

suggests the presence of fluid

within the swelling.

Temperature

If the swelling is superficial, it is often best to

feel the swelling with the back of your hand

to assess the temperature.

Compare it to the surrounding tissues.

Is the swelling hot, warm or cold compared to

the surrounding tissues? Or is there „no

temperature difference to surrounding

tissues‟?


Size

Size should be measured in two dimensions

(length x breadth) in centimetres.

Use a ruler or measuring tape along side the

swelling (so as not to incorporate the height

of a swelling in to the measurement).

If this isn‟t possible (e.g. palpation

of the ovary) then estimate or

describe as an object (e.g.size of an orange)



Transillumination

Shine a (cold) bright light

source against one side of

the swelling.

Room may need to be

darkened, or a blanket or

tube of paper may be used.

Light seen emerging from

the other side is termed as

„transillumination‟.

Transillumination confirms

air or clear fluid within lump.

Document as:

„Swelling transilluminates‟

or „swelling does not

transilluminate‟.

Summary of swelling examination - I

Firstly perform INSPECTION:

Check for Position and Overlying skin

Then check for:

Pulsation and Tenderness

(Remember these steps using mnemonic: Pupils

only play tennis)


Summary of swelling examination - II

Then PALPATE for:

1. Mobility

2. Shape

3. Surface

4. Edge

5. Consistency

6. Depth

7. Indentation

8. Fluctuation

9. Temperature

10. Size

11. Transillumination


Mnemonics

Here are some mnemonics to help you remember palpation of

a swelling (if you need it!) Just pick your favourite:

Medical Students Sitting Exams Can Dive If Forget The

Simple Things

Medical Students Sing Every Christmas Day In Festive

Trousers Sounding Terrific!

Methicillin Sensitive Staph Epidermidis Can Definitely Infect

Fingers, Toes, Scrotum & Testes

Men Secretly Starting Exercise Can Do It For Ten Seconds

Together



Recording your findings

Document your findings as you would any examination in the patient‟s notes (see history taking study guide).

Use black pen.

Patient identified correctly, date & time (24hour)

If you have taken a history from the patient, document the history as usual. However, if you have not taken a history DO NOT fabricate one!

Document your examination findings. All 15 descriptors may not be relevant for deep swellings, but it is usually possible to note size, position, shape, consistency, surface & mobility

A diagram may often be used.

Sign and print your name at the end of the record.

Examination of a Swelling

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