✎ History-taking and clinical

examination
History
• Most patients with a lump feel it frequently and
should be able to answer the following

It is important to be precise with dates and terminology.

Do not write ‘the lump first appeared 6 months ago’, when
you mean ‘the lump was first noticed 6 months ago’.
Many lumps may exist for months, even years, before the
patient notices them.
2. WHAT MADE THE PATIENT NOTICE THE
LUMP
There are four common answers to this question:
‘I felt or saw it when washing.’
‘I had a pain and found the lump when I felt the painful
area.’
‘Someone else noticed it and told me about it.’
‘I found it on self examination’, for example a breast lump
in a female.
 The lump may be painful, and if it is, you must take
a careful history of the pain,
The presence or absence of pain may in itself be
important, particularly if it is the presenting feature.
Pain is usually associated with inflammation, not
neoplastic change.
Many patients expect cancer to be painful and
therefore often ignore a malignant lump just
because it does not hurt.
4. Has the lump changed since it
was first noticed?
The patient should be able to tell you if the lump has got
bigger or smaller, or has fluctuated in size and when they
noticed a change in size.
They may also have appreciated other changes in the
nature of the lump that they can tell you about.
5. Does the lump ever disappear?
A lump may disappear on lying down, or during
exercise, and yet be irreducible at the time of your
examination.
The patient should always be asked if the lump
ever disappears completely, because this physical
characteristic is peculiar to only a few types of
lump.
 6. Has the patient ever had any other
lumps?
You must ask this question because it might not have
occurred to the patient that there could be any
connection between their present lump and a
previous lump, or even a coexisting one (e.g.
neurofibromas or lipomas).
7. What does the patient think caused the
lump?
☞ Lumps occasionally follow injuries or systemic
illnesses known only to the patient.
☘ The location of a lump must be described in
exact anatomical terms, using distances
☘ measured from bony points.
☘ Do not guess distances; use a ta pe measure.
☘ The skin over a lump may be discoloured, may be
inflamed or may have become smooth and shiny,
or thick and rough.
☘ Remember that lumps have three dimensions.
☘ You cannot have a circular lump because a circle is a
plane figure.
☘ Many lumps are not spherical, elliptical or hemispherical,
o Once the shape has been established, it is
possible to measure its dimensions. 2.4cm
☘ Remember that all solid objects have at least three
dimensions:
☘ width, length and height or depth, although the latter
may be impossible to measure clinically.
☘ Asymmetrical lumps will need more measurements
to describe them accurately, and sometimes a
diagram will clarify your written description.
☘ The first feature of the lump that you will feel will
be its surface.
☘ It may be smooth or irregular.
☘ An irregular surface may be covered with smooth
bumps, rather like cobblestones, which can be
called bosselated, or may be irregular or rough.
☘ There may be a mixture of surfaces if the lump is
large.
Temperature
✆ Is the lump hot or of normal temperature?
✆ Assess the skin temperature with the dorsal surfaces of
your fingers, because they are usually dry (free of sweat)
and cool.
Tenderness
Is the lump tender?
If so, is the whole lump tender?
Always try to feel the non-tender part before feeling the
tender area, and watch the patient’s face to ensure that
you are not causing discomfort as you palpate.

✆ The edge of a lump may be clearly defined or indistinct. It

may have a definite pattern.
 ✆Any lump must be composed of one or more of the
following:
Consistency
• The consistency of a lump may vary from very soft to very
hard.
• As it is difficult to describe hardness, it is common practice to
compare the consistency of a lump to well-known objects.
Simple scale for consistency is as follows:
Not indentable – usually bone or calcification.
Hard but not as hard as bone – similar to an unripe apple or pear.
✧ Rubbery: But slightly squashable – similar to a rubber ball.
✧ Spongy: Soft and very squashable, but still with some resilience, like a sponge.
✧ Soft: Squashable and with no resilience, like a balloon.
☘ The consistency of a lump is dependent not only
upon its structure, but also on the tension within the
lump.
☘ Some fluid-filled lumps feel hard,
☘ Some solid lumps are soft; therefore,
☘t h e f i n a l de c isio n ab o u t c omp o si t io n o f a lump
(i .e . w h e t h e r i t is f lu id o r s o lid) ra re l y de p e nds
s o l e l y u p o n a n a s s e s s m e n t o f t h e c o n s i s t e n c y.
☘ Pressure on one side of a fluid-filled cavity makes all
the other surfaces protrude
☘ This is because an increase of pressure within a
cavity is transmitted equally and at right angles to
all parts of its wall.
☘ When you press on one aspect of a solid lump, it
may or may not bulge out in another direction, but it
will not bulge outwards in every other direction.
☘ A percussion wave is easily conducted across a
large fluid collection or cyst but not across a solid
mass.
☘ The presence of a fluid thrill is detected by tapping
one side of the lump, by flicking the middle finger of
the right hand against the thumb, and feeling the
transmitted vibration when it reaches the other side,
where the second detecting left hand is placed
☘ When it is present, a fluid thrill is a diagnostic and
extremely valuable physical sign.
Tr a n s l u c e n c y ( t r a n s i l l u m i n a t i o n )
☘ Light passes easily through clear fluids but does not
pass through solid tissues.
☘ A lump that transilluminates must contain water,
serum, lymph or plasma.
☘ Highly refractile light can also appear to
transilluminate through a large lipoma, while blood
and other opaque fluids do not transmit light.
☘ Requires a bright pinpoint light source and a
darkened room.
☘ The light should be placed on one side of the lump,
not directly on top of it.
☘ Is present when the whole lump glows at a distance
from the light source
☘ Attempts at transillumination with a poor-quality
flashlight in a bright room are bound to fail and
mislead.

☘ The room must be really dark!

Transillumination of a ganglion of the thumb.
Note: Light is visible beyond the site of application.
• Solid and fluid-filled lumps sound dull when
percussed.
• A gas-filled lump, such as a hernial sac containing
bowel, sounds hollow and resonant.

• Lumps may pulsate because they are near to an

artery and are moved by its pulsations (transmitted
pulsation) or because they are connected with the
heart or arterial system (expansile pulsation).
• The most common cause of expansile pulsation is an
aneurysm, with, rarely, very vascular tumours.
☘ Always let your hand rest still for a few seconds on
every lump to discover if it is pulsating.
☘ When a lump pulsates, you must find out whether
the pulsations are transmitted or are expansile.
☘ Place a finger (or fingers if the lump is large) of
each hand on opposite sides of the lump and feel if
they are pushed outwards and upwards .
☘ When they are, the lump has an expansile
pulsation.
☘ When they are pushed only upwards, the lump
has a transmitted pulsation
transmitted pulsation
Expansile pulsation.
Transmitted versus Expansile pulsation.
☘ Some fluid-filled lumps can be compressed until they
disappear.
☘ When the compressing hand is removed, the lump re-
forms.
☘ This finding is a common feature of vascular
malformations and fluid collections that can be pushed
back into a cavity, a joint or a cistern
☘ Compressibility should not be confused with reducibility
☘ A lump that is reducible – such as a hernia – can be
pushed away into another place but will often not
reappear spontaneously without the stimulus of coughing
or gravity.
☘ You should always see if a lump is reducible (disappears) by
gently compressing it.
☘ A reducible lump becomes smaller and then moves to
another place as it is compressed.
☘ It may disappear quite suddenly after appropriate pressure
has been applied.
☘ The lump may return, when you ask the patient to cough,
expanding as it does so.
☘ This is called a cough impulse and is a feature of hernias
and some vascular lumps.
☘ The reduction can be maintained by pressing over the point
at which the lump finally disappeared.
☘ In some ways, the differences between compressibility and
reducibility are semantic.
☘ Always listen to a lump.
☘ A systolic bruit or a machinery murmur (throughout
both systole and diastole) may be audible over
vascular lumps that contain an arteriovenous fistula.
☘ Audible bowel sounds can be heard over a hernia
containing bowel.
☘ By careful palpation, it is usually possible to decide
which structure contains the lump, and what its
relation is to the overlying and deeper tissues.
☘ The attachment of skin and other superficial
structures to a lump can easily be determined
because both are readily accessible to the examiner
and any limitation of their movement easily felt.
☘ The lump should be gently moved while the skin is
inspected for movement or ‘puckering’.
☘ Attachment to deeper structures is more difficult to
determine.
☘ The underlying muscles must be tensed to see if this
reduces the mobility of an overlying lump or makes
it easier or more difficult to Feel .
☘ The former indicates that the lump is attached to the
fascia covering the superficial surface of the muscle
or to the muscle itself; the latter that the lump is
within or deep to the muscles.
☘ Lumps that are attached to bone move very
little, if at all
☘ Lumps that are attached to or arising from vessels
or nerves may be moved from side to side across
the length of the vessel or nerve, but not up and
down along their length.
☘ Lumps in the abdomen that are freely mobile
usually arise from the intestine, its mesentery or
the omentum
☘ Never forget to palpate the lymph glands that
would normally drain lymph from the region
occupied by the lump:
☘ T h e s k i n, m u s c le s a n d b o n e s o f t h e li m b s
a n d t r u n k d ra i n to t h e a x i l la r y a n d
i n g u i n a l g la n d s;
☘ T h e h e a d a n d n e c k to t h e c e r v i ca l g la n d s;
☘ A n d t h e i nt ra - a b d o m i n a l st r u ct u r e s to
t h e p r e a o r t i c a n d p a ra - a o r t i c g la n d s.
☘ It is important to examine the overlying and nearby
skin, subcutaneous tissues, muscles and bones, and
the local circulation and nerve supply of adjacent
tissues.
☘ This is more relevant when examining an ulcer, but
some lumps are associated with a local vascular or
neurological abnormality, so this part of the
examination must not be forgotten, as for example
skin ulceration can occur over a locally advanced
breast cancer.
☘ It is often tempting to examine only the lump about
which the patient is complaining.
☘ This will cause you to make innumerable
misdiagnoses.

☘ You must always examine the whole patient.

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