SURGERY CASE

PRESENTATION
SWELLING/ LUMP
Navya Paul
MBBS 2018
Patient particulars
• Name: Mr ABC
• Age: 20 years
• Address: Alipurduar district, WB
• Occupation: student
• Educational status: undergraduate
• Date of admission: 24/8/21
• Date of examination: 24/8/21
Chief complaints
• Increase in size of swelling on the left of the midline of the lower back
since the last 2 months
History of presenting illness
• The patient was apparently asymptomatic 7 years back when the
mother noticed a swelling on the left of the mid lower back which
was then 1x1 cm in size but has now grown in size since the past 2
months to approximately 2x2 inches
• It is insidious in onset, gradually progressive and painless
Negative history
• No h/o pain
• No h/o fever
• No h/o trauma
• No h/o presence of swellings elsewhere on the body
• No impairment of function or movement of joint
• No loss of body weight
Past history
• No h/o similar complaints in the past
• No h/o any trauma
• No h/o diabetes mellitus, hypertension, asthma or tuberculosis
• No h/o exposure to any radiation
• Left kidney stone removal done 10 years back
Family history
• No h/o of similar complaints in the family
• Mother diagnosed with diabetes mellitus 2 years ago and
hypertension 5 years ago which is currently under control with
medication.
• Father diagnosed and treated for tuberculosis 1 year back
Personal history
• Diet – mixed
• Appetite – normal
• Sleep – adequate and undisturbed
• Bowel and bladder habits- regular
• No h/o of any substance abuse
• No h/o of known drug allergy
Summary
A 20 year old male complains of a swelling to the left of the midline of
the lower back which is insidious in onset, gradually progressive and
painless.
 Examination
• On examination the patient is conscious, cooperative and well oriented to time,
place and person. He is moderately built and well nourished.
• General physical examination:
- No pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema
- Spine- normal
• Vitals
-pulse: 82 bpm
-blood pressure: 120/70 mm Hg
-respiratory rate: 14 breaths/min
-GRBS: 96g/dl
Local examination
Inspection: (in sitting position with the back flexed)
• Solitary swelling, spherical in shape measuring 2x2 inches present 5
cm lateral to the midline of the lower back, with well defined borders,
overlying skin is normal with no scars, sinuses, pigmentation, redness,
black punctum or ulcers and same as that of the surrounding skin.
• No visible pulsation, peristalsis, dilated veins, cough impulse,
movement on respiration/deglutition/protrusion of tongue or any
pressure effect.
Palpation:
• All inspectory findings are confirmed
• The swelling is normal in temperature to touch with no tenderness
• Lobular surface with smooth bumps
• Well defined margins
• Uniform soft consistency with slip sign = positive( when edge of swelling is
palpated with it slips under the finger and does not yield to it)
• Fluctuation: pseudo-fluctuation seen (false sense of fluctuation felt in soft
swellings containing no fluid)
• No fluid thrill
• No cough impulse
• No pulsations
• No reducibility
• Not attached to overlying skin or underlying structures
• Transillumination is negative
• Percussion: Dull note
• Auscultation: no bruit or murmurs heard
• No regional lymph nodes palpable
Systemic examination:
▪ CNS: no focal neurological deficits
▪ CVS: S1 and S2 heard and no murmurs heard
▪ RS: Normal vesicular breath sounds heard
▪ P/A: no hepatosplenomegaly and non tender abdomen
Summary
• A 20 year old male presents with a 2x2 inch, well defined , lobular,
soft in consistency, painless swelling on the left lateral side of the
lower back which slips when palpated on the edge and shows pseudo
fluctuation
Provisional diagnosis
• Most likely to be a LIPOMA as it appears to be benign (slow growing),
with well defined margins, painless, shows slip sign positive and
pseudo-fluctuation, is soft in consistency and has a lobular surface.
 LIPOMA
• Benign tumour arising from fat cells, also called ‘universal tumour’ as it can occur
anywhere in the body where there is fat.
• Types:
1. Single encapsulated
▪ Most common type, subcutaneous swelling, freely mobile, lobular
▪ Pseudofluctuation seen as it appears cystic on palpation as fat behaves as fluid at
body temperature
▪ Most common site- flanks, back , shoulder
2.Multiple lipomatosis:
▪ Multiple lipomas, often tender because of mixed nerve elements
therefore called multiple neurolipomatosis.
▪ Example: Dercum’s disease (Adiposis dolorosa)
▪ Can be mistaken for neurofibromatoses

3. Uncapsulated lipoma (diffuse)

▪ Also called pseudolipoma
▪ Overgrowth of fat w/o capsule
Treatment
• Excision for large lipomas
• Small lipomas removed by incising the skin and squeezing out lipoma
Complications
• Liposarcomas( grows rapidly, warm on palpation, painful, restricted
mobility)
• Calcification
• Intussusception
• saponification
THANK YOU