LOCAL EXAMINATION

Inspection (NSD):
Number: usually single (the commonest multiple swellings: Lymph nodes.)
Site: The anatomical region (usually diagnostic).
Shape:

Rounded Oval Oblong U-shape Butterfly

Should be described in 3D: Hemispherical or dome shaped. If asymmetrical, you may use terms such as 'pear shaped' or 'kidney shaped'.

Size : The largest 2 diameters in (cm x cm)

N.B: 3rd diameter (depth) may be needed.
Width, length and height or depth.

Surface: (better by palpation)

Regular Irregular

Skin over:
- Dilated veins,
- Scar,
- Ulcer,
- Redness as inflammation.
- Black punctum in sebaceous cyst.
Special sign :
- Pulsation as Aneurysm.
- Expansile impulse on cough as Hernia
- Move up & down with deglutition as Thyroid Swelling.
- Move up &. Down with protrusion of Tongue as Thyrogiossal cyst.

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Deep structure : i.e. (Relation to deep muscle).
Ask the patient to contract the muscle against resistance & note the degree of
prominence to differentiate between the swelling deep or superficial the muscle

The Result:
More prominent  Superficial to muscle .
The same size  Within the muscle .
Less prominent  Deep to muscle .

Distal effect :
(V) Vein  oedema & varicose vein (if lower limb)
(A) Artery  colour changes & trophic changes.
(N) Nerve  deformity.
Draining L.Ns: For "metastasis"

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Palpation: (TMSEC D)

Temp:
- By dorsum of hand (More sensitive, less sweat). ‫بظهر اليد‬
- Elevated in inflammation or vascular swellings.
Tenderness:
- Palpate during watching patient's face. ‫بص علي عينه‬

Thrill: If present (systolic or continuous). In:

- Over arterial aneurysm
- Arterio-venous fistula
- Primary toxic goiter.
Mobility: Grasp the swelling & try to push it in all directions.

- Swelling mobile in All directions  subcut in origin

- Swelling mobile in One direction  from longitudinal structure.
- Swelling Fixed  bone.
Site, Shape, Size: (as inspection)
Surface: ‫ريح ايدك علي الكلكيعة‬

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Skin over: ‫زحلق و ارفع‬
- To know if swelling attached to skin or not by:
- pinching up skin over
- Or Sliding the skin over.
- Or Gliding test
Special sign :
1)-Pulsation : may be
 Transmitted pulsation i.e. over artery
 Expansile pulsation i.e. Aneurysm
DD: 2 fingers, one from each hand are placed over the swelling:
- If raised and separated  Expansile swelling.
- If raised only  Transmitted swelling.

2)- Impulse on cough : (swelling connected to a cavity)

True: Expansile impulse on cough as
-Hernia.
-Meningocele.
-Pneumatocele.
False: Transmitted impulse on
cough as Varicose vein

Edge : well defined or ill defined.

N.B. : may be slippery edge as in subcut. lipoma

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Consistency:
- Is the swelling solid or cystic, by (Fluctuation test).
- If solid, is it:
o Firm = Like a Nose
o Hard = Like a Bone
o Soft = Like a Lobule of Ear
o Fleshy= Like muscle
oDoughy= Like dough
- If cystic: there is no subtypes

Fluctuation Test

Defenition: Test used to differentiate between solid and cystic swelling.

Technical Types:
1- Ordinary method:
 The Two index fingers are applied as far as the swelling allows.
 One finger is watching finger & the other move towards it.
 +ve fluctuation test indicates presence of gas or fluid as in cyst.

N.B.:
1- Fluctuation must be done in two perpendicular directions.
2- Pseudofluctuation can be elicited in lipoma
2- Paget’s test:
Indicated if:
1- Swelling Too Tender.
2- Too Tense.
3- Too Deep.
4- Too Small < 2 cm
Depend on:
- Compares the consistency at the center with that at periphery.
- By using only one figure (the index)
Results:
I ) Solid: Center is harder than periphery.
2) Cystic : Center is softer than periphery.

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 3- Cross fluctuation
- Detect if two adjacent swellings connected to each other or not.
- e.g. Psoas abscess in iliac fossa with an extension below inguinal lig.
4- Bipolar fluctuation:
- e.g. in Hydrocele

N.B: Moulding (Indentation)Test:

- Special test done in Soft, or Cystic swellings.

- Press index finger in the swelling for one minute, then relive it.

- If the swelling remain indented, this indicates that the content pultaceous
material (putty-like).
- Seen in:
- Sebaceous cyst.

- Dermoid cyst.
- Colonic mass with fecal impaction.

Compressibility/ Reducibilty:
Compressibility
Disappear partially or completely on pressing the whole swelling &
return to its normal size on releasing pressure" e.g. Saphena Varix.
Reducibility
Decrease in size or disappear when compressed into certain direction &
reappear only on cough" e.g. Hernia

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 Distal effect:
1- Deep structure i.e (Muscle)
Examine mobility before & after contracting muscle.
a)- In the superficial swelling:
Before After Result

Mobile Mobile Not attached.

Mobile Fixed Attach to muscle.

Mobile Limited Attach to fascia

b)- In deep swelling: clinically can’t be elicited.

2- Distal effect:
 (V) Vein oedema, (pitting or non pitting).
 (A) Artery : pulsation .
 (N) Nerve : sensory & motor examination.
3- Draining L.Ns For "metastasis"

Percussion:
Over swelling may be
Resonent = gas swelling e.g Hernia.
Dullness = solid or cystic e.g Lipoma.

Auscultation:

Over vascular swelling may be

- Systolic murmur as Aneurysm.
- Continuous murmur as A-V Fistula
- Venous hum as in portal hypertension
- Gurgling of intestine . as Enterocele.

Transillumination:
As Hydrocele or Meningocele

Diagnosis
[1] Anatomical Site or Organ involved.
[2] Pathological  Congenital, traumatic, inflammatory, neoplastic,…..
[3] Functional Complicated or not Compensated or not (Liver)

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