Clinical examination of swelling

1. Examination of the swelling
By
Dr.K.Priyatham

2. General considerations
• You should wash your hand in the presence
of the patient before beginning the physical
examination
• A new patient warrants a complete
examination, regardless of chief complaint
• The sequence of comprehensive examination
should maximize the patient’s comfort
• As a beginner, you should avoid interpreting
your findings for the patient

3. PATIENT’S PROBLEM
HOW TO SOLVE IT?
 HISTORY
 CLINICAL EXAMINATION
 CLINICAL DIAGNOSIS (dif-dx)
 INVESTIGATIONS
 FINAL DIAGNOSIS
 TREATMENT

4. What are the five important points,
you have to do, before
examination-taking?????

5. IMPORTANT POINTS BEFORE
EXAMINATION-TAKING
 Introduce yourself
 Explain yourself
 Take patient permission to do the examination
 Ideal exposure
 Define the Position of both
 Treat with respect

6. CLINICAL EXAMINATION
 Observe while history taking
• General health
• Intelligence
• Attitude
• Mental state
• Posture/ Mobility
 Ask for a nurse when examining females
 Patient’s permission

7. The comprehensive physical
examination; first impressions
• General survey: general state of health;
height, weight, build, sexual development,
motor activity, facial expression, state of
awareness or level of consciousness.
• Vital signs: blood pressure, pulse number
and respiratory rate.
• Skin: color, lesions. Inspection and
palpation of hair and nails.

8. CLINICAL EXAMINATION
Four basic techniques:
• Inspection
• Palpation
• Percussion
• Auscultation

9. INSPECTION
• 1. SITE- EXACT ANATOMICAL LOCATION
IMPORTANT AS SOME SWELLINGS OCCUR
IN ATYPICAL POSITIONWHICH IS
DIAGNOSTIC
• EXAMPLES
– POST AURICULAR DERMOID-BEHIND EAR
– EXTERNAL ANGULAR DERMOID –LATERAL END
OF EYE BROW
– MENINGOCELE- OVERTHE BACK IN MIDLINE

10. *Image via Bing
EXTERNAL ANGULAR DERMOID

11. *Image via Bing
EXTERNAL ANGULAR DERMOID

12. *Image via Bing
POST AURICULAR DERMOID

13. *Image by 12498905@N02 via Flickr
SUB MANDIBULAR DERMOID

14. *Image by 48276084@N00 via Flickr

15. *Image via Bing
DERMOID CYST OF SCALP

16. *Image via Bing
DERMOID CYST IN MID LINE

17. *Image via Bing
ATYPOCAL LOCATION OF DERMOID – MEDIAL END OF EYE BROW

18. *Image via Bing
MENINGOCELE

19. *Image via Bing
MENINGOCELE

20. 2.NUMBER
• USUALLY SINGLE , SOMETIMES MULTIPLE
• MULTIPLE EXAMPLES
– MULTIPLE NEUROFIBROMATOSIS(VON RECK
LING HAUSENS DISEASE)
– MULTIPLE LIPAMATOSIS(DERCUMS DISEASE)
– DIAPHYSEAL ACLASIS
– HYDRADENITIS SUPPURATIVA
– MULTIPLE LYMPHOGLANDULAR SWELLINGS

21. *Image via Bing

22. *Image via Bing

23. *Image via Bing
MULTIPLE LIPAMATOSIS

24. *Image via Bing
HYDREDENITIS SUPPURATIVA OF AXILLA

25. *Image via Bing

26. *Image via Bing

27. 3.SHAPE
• SPHERICAL
• OVOID
• KIDNEY /BEAN SHAPED/RENIFORM
• IRREGULAR

28. 4.SIZE
 EXACT SIZE USING A MEASURING TAPE
 LONGITUDINAL & TRANSVERSE ON
INSPECTION
 DEPTH BETTER JUDJED ON PALPATION
• USUALLY NOTED IN CENTIMETRES

29. 5.SURFACE
• COLOUR
• SPECIAL CHARACTER OF SURFACE
• OVERLYING SKIN

30. A)COLOUR
• ARTERIAL HAEMANGIOMA – BRIGHT RED
• VENOUS HAEMANGIOMA— PURPLE
• MALIGNANT MELANOMA- BLACK
• BENIGN NAEVUS – BLACK
• RANULA –BLUE

31. *Image via Bing
CAPILLARY HAEMANGIOMA OVER FORE HEAD

32. BENIGN NEVUS

33. *Image via Bing
BENIGN NEVUS

34. *Image via Bing
HERIDITARY DYSPLASTIC NAEVUS SYNDROME

35. *Image via Bing

36. *Image via Bing
MALIGNANT MELANOMA

37. *Image via Bing

38. *Image via Bing
MALIGNANT MELANOMA OF FOOT

39. *Image via Bing
RANULA

40. *Image via Bing

41. *Image via Bing
RANULA OF RIGHT SUBLINGUAL

42. b)Character of surface
• TWO CHARACTERISTIC SURFACES ON
INSPECTION
– CAULIFLOWER SURFACE – SQUAMOUS CELL
CARCINOMA
– FILIFORM BRANCHED SURFACE – PAPILLOMA
(IRREGULAR NUMEROUS BRANCHED
SURFACE)

43. *Image via Bing
SQUAMOUS CELL CARCINOMA

44. *Image via Bing

45. *Image via Bing
SCC OF TONGUE

46. *Image via Bing
FILIFORM SURFACE OF PAPILLOMA

47. *Image via Bing
INDONESIAN TREE MAN
H.P.V. AFFECTING HANDS &LEGS

48. c)Skin over lying swelling
• TENSE , SHINYWITH PROMINENTVEINS – SARCOMA
• RED &EDEMATOUS – INFLAMMATORY
• BLACK PUNCTUM – SEBACEOUSCYST
• PIGMENTATION-MOLES , NAEVI OR REPEATED X-RAYS
• SCAR
– PREVIOUSOPERATION(REGULAR SCARWITH SUTURE MARKS)
– INJURY(REGULAR SCAR)
– SUPPURATION(PUCKERED ,BROAD &IRREGULAR)
– PEAU - D ORANGE APPEARANCE(MAINLY IN CA. BREAST)
• ULCERS

49. *Image via Bing
ABSCESS

50. *Image via Bing
ABDOMINAL WALL ABSCESS

51. *Image via Bing
NASAL ABSCESS

52. *Image via Bing
INFECTED SEBACEOUS CYST WITH PUNCTUM

53. *Image via Bing
SOFT TISSUE SARCOMA

54. *Image by 88761406@N00 via Flickr
POST THYROIDECTOMY SURGICAL SCAR

55. *Image via Bing

56. 6.VISIBLE PULSATIONS
• PULSATION
– A MOVEMENT OR INCREASE IN SIZE
SYNCHRONOUS WITH EACH HEART BEAT
– 2TYPES
• EXPANSILE PULSATIONS – SWELLINGS ARISING
FROM ARTERIES EX: AORTIC ANEURYSM , CAROTID
BODYTUMOUR
• TRANSIMITTED PULSATIONS – SWELLINGS CLOSE
TO ARTERIES
• REMEMBER NOTTOTOUCHTHE PATIENT DURING
INSPECTION

58. 7.VISIBLE COUGH IMPULSE
 PERFORMED WHEN SWELLING IS OVER
ABDOMEN,CHEST,SPINAL CANAL OR
CRANIUM
 COUGH IMPULSE
 VISIBLE INCREASE IN THE SIZE OF SWELLING
SYNCHRONOUS WITH COUGH
 POSITIVE IN SWELLINGS COMMUNICATING
WITH ABDOMEN,THORACIC CAVITY,SPINAL
CANAL OR CRANIAL CAVITY

60. POSITIVE COUGH IMPULSE
• HERNIA
• MENINGOCELE
• VARICOCELE
• SAPHENAVARIX
– IN CHILDREN CRYING ACTS AS COUGHING

61. 8.VISIBLE PERISTALSIS
• OBSERVED INABDOMINAL LUMPSAND
INGUINAL SWELLINGS
• CONGENITAL HYPERTROPHIC PYLORIC
STENOSIS –VISIBLE GASTRIC PERISTALYSIS
• INGUINAL HERNIAS (ENTEROCELE)
INTESTINAL PERISTALYSIS
• LUMPS DUETO INTESTINAL MALIGNANCY
PERISTALYSIS IS SEEN

63. 9.MOVEMENT WITH RESPIRATION
 SEEN IN ABDOMINAL LUMPS
 SWELLINGS ARISING FROM
 STOMACH
 LIVER
 SPLEEN
 GALLBLADDER
 HEPATIC FLEXURE OF COLON
 SPLENIC FLEXURE OF COLON
 RENAL LUMP THOUGH NOT IN CONTACT WITH
DIAPHRAGM ,MOVES WITH RESPIRATION

64. 10.Movement with deglutition
• IN CASE OF NECK SWELLINGS
– SWELLINGS MOVING WITH DEGLUTITION
• THYROID SWELLING
• THYROGLOSSAL CYST
• THYROGLOSSAL FISTULA
• SUBHYOID BURSA
• PRE/PARA TRACHEAL LYMPH NODES
• EXTRINSIC CARCINOMA OF LARYNX

66. WHY THYROID MOVES UP WITH DEGLUTITION?
• THYROID IS ENCLOSED IN PRETRACHEAL
FASCIA
• PTF ATTACHES TO THYROID &CRICOID
CARTILAGES(BERRY’S LIGAMENT)
• SUPERIOR CONSTRICTOR MUSCLE
CONTRACTION DURING DEGLUTITION
• THESE CARTILAGES MOVE UP
• ALONGWITHTHESETHYROID MOVES UP

67. 11)MOVEMENT WITH TONGUE PROTRUSION
• IN CASE OF MID LINE NECK SWELLINGS
• EG:THYROGLOSSAL CYST &FISTULA
• WHY?
– ATTACHEDTO FORAMEN CAECUM OFTONGUE

68. 12)PRESSURE EFFECTS
• WHEN SWELLING IS PRESENT ON LIMBS
– AN AXILLARY SWELLING WITH LIMB EDEMA –
LYMPHNODAL SWELLING
– PARESIS – PRESSURE ON NERVES
– WASTING OF MUSCLES OF DISTAL LIMB-
TRAUMATIC SWELLING(WASTING DUETO
NON-USE/INJURY TO NERVES)
– SWELLING IN NECK WITHVENOUS
ENGORGEMENT(RETROSTERNAL EXTENSION)

69. PALPATION
• DEFINITE CLUETO DIAGNOSIS
• METHODICAL,FOLLOW DEFINITEORDER
• BE GENTLE
• SHOULD NOT HURTTHE PT.

70. 1.TEMPERATURE
• IT IS AN ABSOLUTE STANDARD PRACTICE
TOTEST FORTEMP FIRST-WHY?
• BEST FELT BY BACK OFTHE HAND-WHY?
• INCREASED IN
– INFLAMMATORY SWELLING
– WELLVASCULARISEDTUMOURS- SARCOMA

71. 2.TENDERNESS
• PAIN DUETO PRESSURE EXERTED OVER
THE SWELLING ISTENDERNESS
• PALPATE GENTLY OVER ALLTHE AREA
• IT IS A SIGN
• FEATURE OF
– INFLAMMATORY SWELLINGS
– SWELLING RELATEDTO NERVES -
NEUROFIBROMA

72. 3.SIZE& SHAPE
• CONFIRMVERTICAL & HORIZONTAL
DIMENSIONS
• NOTETHETHIRD DIMENSION DEPTH
WHICH COULD NOT BE EXACTLY
DETERMINED BY INSPECTION

73. 4.SURFACE
• WITH PALMAR SURFACE
– SMOOTH –CYSTIC SWELLINGS
– LOBULARWITH SMOOTH BUMPS-LIPOMA
– NODULAR –MULTI NODULAR GOITRE/MATTED
LYMPH NODES
– IRREGULAR - CARCINOMA

74. *Image via Bing
SMOOTH SURFACE OF A SEBACEOUS CYST

75. *Image via Bing

76. M..N.G. WITH NODULAR SURFACE

77. 5.EDGE
• 1)WELL DEFINED & REGULAR – BENIGN
NEOPLASMS
• 2)WELL DEFINED & IRREGULAR –
MALIGNANT NEOPLASM
• 3)ILLDEFINED &DIFFUSE –INFLAMMATORY
SWELLINGS

78. *Image by 9085776@N08 via Flickr
ABSCESS WITH ILL DEFINED MARGINS

79. *Image by 72310117@N07 via Flickr
LIPOMA WOTH WELL DEFINED MARGINS

80. *Image by 78523246@N00 via Flickr
LARGE LIPOMA WITH WELL DEFINED MARGINS

81. *Image by 78523246@N00 via Flickr

82. *Image via Bing
IRREGULAR BORDERS IN CARCINOMA BREAST

83. SLIP SIGN
• TO DEFFERENTIATE BETWEEN LIPOMA
AND CYSTIC SWELLING(BOTH HAVE
WELL DEFINED ,REGULAR BORDERS)
• WHEN EDGE OF A SWELLING IS
PALPATEDWITH A FINGER ,IF IT SLIPS
UNDERTHE FINGER,. DOES NOTYIELD
TO IT , IT IS A LIPOMA,IF IT YIELDSTO
FINGER IS A CYST
*Image via Bing

84. 6.CONSISTENCY
• SOFT – LIPOMA
• CYSTIC- CYSTS &CHRONIC ABSCESSES
• FIRM –FIBROMA
• HARD BUTYIELDING-CHONDROMA
• BONY HARD-OSTEOMA
• STONY HARD- CARCINOMA
• VARIABLE CONSISTENCY- MALIGNANCY

85. HOW TO ASSESS CONSISTENCY
• SOFT – EAR LOBULE,ALAE OF NOSE
• FIRM-TIP OF NOSE,UN CONTRACTED
MUSCLE
• HARD -BRIDGE OF NOSE,CONTRACTED
MUSCLE

86. SIGN OF MOULDING OR INDENTATION
 LOOK FOR THIS SIGN IN SOFT &CYSTIC
SWELLINGS
 PRESS A FINGER INTO SWELLING FOR 1-2 MTS AND
RELEASE IT IF SWELLING REMAINS INDENTED IT
INDICATES PRESENCE OF PULTACEOUS
MATERIAL(PUTTY LIKE)
 SEEN IN
 1.SEBACYOUS CYST
 2.DERMOID CYST
 3.COLONIC MASS WITH FAECAL MATTER

87. PAGET’S TEST
• DONE FOR SMALL SWELLINGSTO KNOW
THE CONSISTENCY(CYSTIC/SOLID)
• THE CENTRE AND PERIPHERIES ARE
PALPATEDWITH INDEX FINGER
– CYSTIC SWELLING FEELS SOFTER AT CENTRE
THAN PARIPHERY
– SOLID SWELLING FEELS FIRMER ATCENTRE
THAN PERIPHERY

88. SPECIAL TESTS
• DONE IN CASE OF SOFT/CYSTIC SWELLING
– 7.FLUCTUATION
– 8.TRANSILLUMINATION
– 9.COUGH IMPULSE
– 10.REDUCIBILITY
– 11.COMPRESSIBILITY
• IN SOLID SWELLINGS DIRECTLY PROCEED
TOTEST FOR RELATIONTO OTHER
STRUCTURES

89. 7.FLUCTUATION
• TRANSMISSION OF IMPULSE INTWO
DIRECTIONS AT RIGHT ANGLESTO EACH
OTHER
• IMPLIES PRSENCE OF FLUID INTHE
SWELLING

90. HOW TO ELICIT FLUCTUATION?
 IF THE SWELLING IS MOBILE FIRST FIX IT OR
ASK THE ASST. TO HOLD IT
 KEEP 2 INDEX FINGERS ON OPPOSITE POLES
 WHEN ONE FINGER IS PRESSED THE FINGER
AT OPPOSITE END FEELS THE IMPULSE &
PASSIVELY LIFTED UP
 REPEAT THE MANUVERE IN A PLANE AT RIGHT
ANGLES TO THE 1ST ONE
 IF IMPULSE IS FELT IN BOTH PLANES IT IS A
POSITIVE FLUCTUATION TEST

92. LAW BEHIND FLUCTUATION!
• PASCAL’S LAW
– PRESSURE EXERTEDTO A FLUID ISTRANSMITTED
EQUALLY IN ALLTHE DIRECTIONS
*Image via Bing

93. PRINCIPLES WHILE DOING FLUCTUATION TEST
• ALWAYS PERFORM IN 2 DIRECTIONS AT
RIGHT ANGLESTO EACH OTHER
• TWO FINGERS SHOULD BE KEPTAS FAR
APART AS POSSIBLE
• FREELY MOBILE SWELLINGS SHOULD BE
FIXED FIRST(AS IN HYDROCELE)
• SMALL SWELLINGS –WATCHING FINGER &
DISPLACING FINGER
• VERY LARGE SWELLINGS MORETHAN ONE
FINGFR SHOLD BE USED

95. PSEUDO FLUCTUATION
 A FALSE SENSE OF FLUCTUATION FELT IN LARGE
SOFT SWELLINGS CONTAINING NO FLUID
 SEEN IN
 LARGE LIPOMA
 MYXOMA
 SOFT FIBROMA
 VASCULAR SARCOMA
 FAIL TO EXPAND IN OTHER PARTS OF A SWELLING
LIKE A TRUE FLUCTUANT SWELLING

96. CROSS FLUCTUATION
• FLUCTUATION BETWEENTWO SEPARATE
CYSTIC SWELLINGS COMMUNICATING
WITH EACH OTHER
• SEEN IN
– COMPOUND PALMAR GANGLION
– PSOAS ABSCESS
– PLUNGING RANULA

97. 8.TRANSILLUMINATION
• DEMONSTRATION OFTRANSMISSION OF
LIGHTTHROUGH A SWELLING
• POSITIVE IN SWELLINGS CONTAINING
CLEAR FLUID ANDTHINTRANSPARENT
WALLS
• NOTRANSILLUMINATION IFWALL ISTHICK,
ORTURBID FLUID IS PRESENT(BLOOD,PUS,
LYMPH)
• DARK ROOM ,TRANSILLUMINOSCOPE

99. BRILLIANTLY TRANSILLUMINANT SWELLINGS
 1.CYSTIC HYGROMA
 2.EPIDIDYMAL CYST
 3.MENINGOCELE WITH THIN SKIN
 4.RANULA
 5.CONGENITAL HYDROCELE

100. 9.COUGH IMPULSE
• PERFORMED IN SWELLINGS LIKELYTO BE IN
CONTACTWITH ABDOMINAL ,CRANIAL
,SPINAL OR CHEST CAVITY
• SWELLING IS HELDWITH FINGERS AND
PATIENT IS ASKEDTO COUGH
• IFTHE SWELLING BECOMESTENSE OR
INCREASES IN SIZE IT IS POSITIVE COUGH
IMPULSE
• IN CHILDREN CRYING ACTS AS COUGH

101. SWELLINGS WITH POSITIVE COUGH IMPULSE
• IN CONTINUITYWITH ABD. CAVITY
– HERNIA
– ILIO-PSOAS ABSCSS
– LUMBAR ABSCESS
• IN CONTINUITYWITH PLEURAL CAVITY
– EMPYEMA NECESSITANS
• IN CONTINUITYWITH SPINAL /CRANIAL
CAVITY
– SPINAL/CRANIAL MENINGOCELE

102. 10.REDUCIBILITY
• INDICATION SAME AS FOR COUGH
IMPULSE
• PATIENT IS ASKEDTO RELAX
• SWELLING IS COMPRESSED FROMALLTHE
SIDES UNIFORMLY
• REDUCIBLE SWELLINGS DECREASESIN SIZE
OR COMLETELY DISAPPEAR

103. REDUCIBLE SWELLINGS
• 1.HERNIA
• 2.MENINGOCELE
• 3.VARICOCELE
• 4.SAPHENAVARIX
– A REDUCIBLE SWELLING ONCE REDUCED
REAPPEARS ONLY BY STRAINING,COUGHING,
OR FORCE OF GRAVITY AS IT INVOLVES
DISPLACEMENT OFVISCERSTO AN ADJOINING
CAVITY

104. 11.COMPRESSIBILITY
• WHEN PRESSURE ISAPPLIEDTO A
SWELLING IT DECREASES IN SIZE AND
WHEN PRESSURE IS RELEASED SWELLING
REGAINS ITS SIZE ITSELFWITH OUT ANY
EXTERNAL FACTORLIKE STRAINING OR
COUGHING
• CHARECTARISTIC SIGN OFVASCULAR
HAEMANGIOMA

106. 12.PULSATILITY
 WHEN FINGER IS PLACED OVER A PULSATILE
SWELLING IT RAISESWITH EACH BEAT
 TO TYPES OF PULSATIONS
 TRANSMITTED PULSATIONS- SEEN IN SWELLINGS
PRESENT NEAR AN ARTERY
 EX:CA STOMACH LUMP NEAR ABD.AORTA
 EXPANSILE PULSATIONS-SEEN IN SWELLINGS
ARISING FROM ARTERIES
 EX:AORTIC ANEURYSM

108. HOW TO DIFFERENTIATE?
• TWO FINGERSARE PLACED OVERTHE
SWELLING AND FINGER MOVEMENTS ARE
NOTED
• TRANSMITTED PULSATIONS – FINGERSARE
SIMPLY LIFTED UP
• EXPANSILE PULSATIONS- FINGERSARE
LIFTED UP AND MOVE APART

110. IN AN ABDOMINAL LUMP?
• KNEE ELBOW POSITION
– WHEN KEPT IN KNEE ELBOW POSITION
• PULSATIONS DISAPPEAR –TRANSMITTED
PULSATIONS
• PULSATIONS PERSIST –EXPANSILE PULSATIONS

111. 13.FIXITY TO SKIN
• SKIN PINCHED OVER DIFFERENT PARTS OF
THE SWELLING -CANNOT BE PINCHED IF
FIXEDTO SKIN
• SKIN IS MADETO MOVE OVERTHE
SWELLING-THE SKINWILL NOT MOVE IF IT
IS FIXEDTO SKIN
• SWELLINGS ARISING FROM SKINARE FIXED
TO SKIN EX:SEBACEOUS CYST , PAPILLOMA
, EPITHELIOMA

112. 14.RELATION TO SURROUNDING STRUCTURES
• 1)SUBCUTANEOUSTISSUE
– SWELLINGS IN SUB CUTANEOUSTISSUE ARE NOT
ADHERENTTO SKIN OR UNDERLYING MUSCLE
– LIPOMA-PUSHED SIDEWAYS PUCKERING IS SEEN IN SOME
PLACES – DUE PRESENCE OF FIBROUS SEPTA
• 2)DEEP FASCIA
– SWELLING ARISING FROM DEEP FASCIA WILL NOT BE AS
MOBILE AS SUBCUTANEOUS SWELLINGS
– IT IS DIFFICULT MAKE OUT FIXATIONTO DEEP FASCIA AS
DEEP FASCIA CANNOT BE MADETAUT
• EVEN IFTUMOUR ISATTACHEDTO UNDERLYING DEEP FASCIA
&MUSCLETUMOUR CAN BE MOVED SIDEWAYS

113. 3)RELATION TO MUSCLE
• RELATION SHIPTO MUSCLE IS KNOWN BY
THROWINGTHE CONCERNED MUSCLE
INTO CONTRACTION
– TUMOURS IN SUB CUTANEOUS TISSUE-
BECOME MORE PROMINENT &REMAIN MOBILE
– TUMOURS ARISING FROM MUSCLE /
INCORPORATED IN MUSCLE-FIXED&IMMOBILE
– TUMORS DEEPTO MUSCLE –LESS PROMINENT,
OR DISAPPEARS,DIFFICULTTO PALPATE

114. 4)SWELLING IN RELATION TO TENDON
 MOVES ALONG WITH TENDON&BECOMES
FIXED WHEN MUSCLE CONTRACTS
 5)IN CONNECTION WITH VESSELS &NERVES
 DO NOT MOVE ALONG VESSELS OR NERVES
BUT MOVE TO A LITTLE EXTENT AT RIGHT
ANGLES TO THEIR AXES
 6)IN CONNECTION WITH BONE
 IS ABSOLUTELY FIXED IRRESPECTIVE OF
MUSCLE CONTRACTION

115. PERCUSSION
• LIMITEDVALUE IN SWELLINGS
– 1.TYMPANIC NOTE
• ENTEROCELE
• PHARYNGOCELE
– 2.HYDATIDTHRILL
• HYDATID CYST
3. Dull – solid swellings

116. AUSCULTATION
• BRUIT OVER PULSATILE &VASCULAR
SWELLINGS
• BRUIT
– SHORT,MEDIUM PITCHED MURMUR HEARD
OVERTHE SWELLING WITH EACH PULSE WAVE
• EX:ANEURYSM
• THYROTOXIC GOITRE

117. REGIONAL LYMPH NODES
 DRAINING LYMPH NODES EXAMINED IF
INVOLVED NEXT HIGHER GROUP EXAMINED
 IF THE SWELLING ITSELF IS ALYMPH NODE
EXAMINE
 1.OTHER LYMPH NODAL GROUPS
 2.SPLEEN
 3.LIVER
 TO EXCLUDE SYSTEMIC CAUSE
 EXAMINE DRAINAGE AREA TO EXCLUDE INFECTION

118. PRESSURE EFFECTS
• 1.OVER BONE – FEEL FOR BONY EROSION
– AS IN DERMOID CYST
• 2.IN LIMBS
– DISTAL PULSES- PRESSURE OVER ARTERIES
– EDEMA &DILATEDVEINS – PRESSURE OVER
VEINS
– PARESIS& MUSCLE WASTING – PRESSURE
OVER NERVES
• MOVEMENTS OF JOINTS

119. *Image via Bing
WASTING OF THENAR MUSCLES DUE PRESSURE OVER MEDIAN NERVE

120. *Image via Bing
SPINAL LIPOMA

121. GENERAL EXAMINATION

123. *Image by 40501877@N04 via Flickr
THANKS FOR PATIENT LISTENING