Clinical - General Swelling examination

MRCS Clinical Examination
Scheme & Test Interpretetion

Modified  by MAW 2009

هذا الورق وقف لوجه الله تعالى
وهو تعديل و اضافة على ملازم سابقة لأساتذتنا
واضافة لمعلومات من كتب اخرى مفصلة
ليغطى 99% من الفحص العملى و تفسيره
ملحق به ورق اخر لأهم الأسئلة
نفع الله الناس به ووفق الجميع لطلب العلم

Swellings (Lumps & Bumps)
1-         Onset (When 1st noticed), Duration (Long/ Short)                                                         
2-         Complaint (Pain / Other lump / Change)                                    
3-         Treatment (Previous surgery / Insulin in diabetic ulcer)               
4-         Cause (Trauma)                                                                       

For any swelling examine:
Swelling Examination

Introduce yourself
Exposure:  till area L.N. drainage
UL → elbow (epitrochlear L.N.) although nonspecific + axillary L.N.
LL → groin (inguinal L.N.) although non-specific + popliteal L.N. for  leg
H & N → to (clavicle cervical L.N.)
Trunk & Back → axilla (axillary L.N.)
1-    Inspection (4SMS) Be Fluent & very fast in swelling examination even forget points
a-  Site
b-  Shape
c-  Size (in cms)
d-  Skin: Scars  فى اى جروح او عمليات(Ask about hidden scars?) – Sinuses – dilated vs – Redness
e-   Relation to Muscle: contraction ms → more palpable = superficial to ms
           less palpable = deep to ms
- Other sweelings (same or L.N.)
f-   Special ccc: impulse on cough – thrill – pulsatile
2-    Palpation Ask about painful area first (TT ESCR SMSL)
a-  Temperature
b-  Tenderness  
c-  Edge (well defined/ Ill defined/ Slippery)
d-  Surface (Smooth/ Irregular)
e-  Consistency (soft/ firm/ hard/ cystic) - if soft vs cystic do Paget test  
f-  Relations:      Mobility in 2 perpendicular directions
Relation to Skin (not attached/ teethered/ fixed) &
Relation to Muscle: contraction ms → more palpable = superficial to ms
                     less palpable = deep to ms
g-  Special Tests
·  Fluctuation (Paget’s test1) & Trans-illumination if suspect cystic (querry soft vs cystic)
·  Compressibility2 / Reducibility3                 ·  Pulsatile4 / Expansile5
·  Thrill                                                       ·  Fixation (with skin & deep structures)
h-  L.N. & other swellings (very..very imp.)
3-         Percussion (Dull / Resonant)
4-         Auscultation (Bruit / Bowel sounds)

I would like to finish my examination by:
 1-        Examination of draining lymph nodes هام جدا
 2-          Assessing the neurovascular status of the limb/area (feel distal pulse)

1 Paget test: Applying intermittent pressure by the index finger of one hand between two fingers of the other hand
2 Compressiblity: Lump disappears when compressed, then reform spontaneously when compressing hand is removed
3 Reducibility: Lump can be 'pushed' away into a different place, lump will not reform spontaneously and requires an
    additional force e.g. gravity, raised intra-abdominal pressure
4 Pulsatile : If  a finger is placed on either side of a lump → pushed one direction (lump is near to an artery)
5 Expansile: If  a finger is placed on either side of a lump → forced apart with every pulsation

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