SWELLING

Patient particulars

Name, Age, Gender,

Address
Occupation
Date of admission
Date of examination.

Chief complaints.
Lump or swelling.

History of present illness.

Swelling/lump.
 Duration
 Mode of Onset-sudden/insidious
 Progression
 Exact site
 Pain:- onset, duration ,progression Site, nature, type, radiation, aggrevating
factor, Reliving factors .
 Fever
 Presence of any other lumps
 Secondary changes
 Impairment of function-movement, disfiguring, dyspnea, dysphagia.
 Recurrence of the swelling.
 Loss of body weight
 Trauma

Past history.
H/o similar complaints in the past.
H/o recurrence of the swelling
H/of trauma
H/o hypertension, diabetes, tuberculosis, malignancy
H/o surgical and medical interventions in the past.

Treatment history
History of allergy to food and any drug.
Menstrual history (in females)
Marital and obstetric history. (In females)
Family history.
H/o similar complaints in the family (in case of malignacies)

Personal history.
 Vegetarian /non vegetarian , Appatite
 Sleep
 Bowel and bladder habits
 Subactance abuse-smoking,alcohol.

Summary after history.

General physical examination.

Patient is conscious /not , Orientation to time ,place ,person.

Built Nourishmnet.

Vitals:
Pulse.
Blood pressure.:right arm ,supine position. Respiratory rate,rhythm,type.
Temperature.

Pallor , icterus, Cyanosis , clubbing, edema,

Lymphadenolathy, Leukonychia

Height Weight BMI.

Head to toe examination.

Local examination.
INSPECTION
1. Situation- Site,relation to bony point, Extension
2. Size
 3. Shape-oval/spherical/irregular
4. Surface-smooth/ulcerated/lobulated/fungated
5. Colour
6. Edge-well defined/ill defined.
7. Number
8. Pulsation
9. Viaible Peristalsis
10. Dilated veins
11. Movement with respiration
12. Impulse on coughing
13. Movement with deglutition
14. Movement with protrusion of tongue
15. Skin over the swelling-red, edematous, tense, venous prominence,
blackpunctum, scar, pigment, ulcer.
16. Any pressure effect
17. Surrounding area.

PALPATION
1. Local rise of temperature
2. Tenderness
All the inspectory findings should be confirmed
3. Size, Shape & Extent
4. Surface
5. Edge
6. Consistency-soft/firm/hard/bony hard
7. Fluctuation
8. Fluid thrill
9. Translucency
10. Impulse on coughing
11. Reducibilty
12. Compressibility
13. Pulsatility- expanisle/ transmitted.
14. Sign of moulding/indentation
15. Fixity to overlying skin
16. Relation to surrounding structures.

 State of regional lymph nodes

 Percussion.
 Ascultation.
 Measurement
 Movement.
 Any pressure effect- arterial pulsation distal to the swelling, any sensory
deficit/ muscle wasting
Systemic examination.
Carsiovascualr system
Respiratory system
Abdomen
Central nervous system
Locomotory system

Provisional diagnosis

Summary

Investigation
Treatment -Medical, surgery
Follow-up.
Prognosis

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 his wife 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
• 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 26 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:
 The swelling is normal in temperature to touch with no tenderness
 All inspectory findings are confirmed
 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
 Trans illumination 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 26 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.]

QUESTIONS:
1. Name the swellings which are brilliantly transilluminant.

2. Give some examples where you get cough impulse.

3. Compressible Vs Reducible

4. Transmitted pulsation vs Expansile pulsation

5. Demonstrate fluctuation

6. How will you demonstrate fluctuation for small swellings?

7. What is Paget’s test?

8. What is pseudo-fluctuation?

9. What is cross fluctuation?

10. Name some swellings where you find cross fluctuation.

11. How will you demonstrate fixity to skin?

12. How will you demonstrate muscle fixity?

13. Why the muscle fixity test is done by moving the swelling in both planes?
14. When will you say the swelling is fixed to an underlying bone?

15. Investigations done for small swellings before surgery

16. What local anaesthesia will you infiltrate

17. What is sebaceous cyst?

18. Why is it also called as epidermoid cyst?

19. Cardinal features of sebaceous cyst?

20. Name the organism found in wall of sebaceous cyst.

21. What are the complications of sebaceous cyst/

22. What is Cock’s peculiar tumour?

23. Features of sebaceous cyst over scrotum & how will you manage?

24. Treatment of sebaceous cyst.

25. What type of incision will you make for excision of sebaceous cyst?

26. What is a dermoid cyst?

27. What are the common sites of dermoid cyst?

28. Types of dermoid cyst.

29. Clinical features of dermoid cyst.

30. What is sequestration dermoid?

31. What is Implantation dermoid?

32. What is Tubulo dermoid, give some examples.

33. Give some examples of teratomatous dermoid.

34. Clinical features of Lipoma.

35. What are the varieties of lipoma?

36. Why is it known as universal tumor?

37. What are the types of lipoma based on the type of tissue present/

38. Tell some types of lipoma based on anatomical locations.

39. What are the complications of lipoma?

40. Which are the anatomical sites where lipoma can cause dangerous

complication?

41. Which lipoma undergoes malignant change?

42. What are the features of Sarcomatous change in lipoma?

43. What is Hamartoma?

44. What is a Desmoid tumour?

45. What is Dercum’s disease/ Adiposis dolorosa?

46. What is lipoma arboreescens?

47. What is the treatment of lipoma?

48. Which type of incision will you make?

49. What is hemangioma & tell its types?

50. Tell the treatment of hemangioma.

51. What is Ganglion cyst?

52. What is Neurofibroma?

53. What is Von Reckling Hausen’s disease?

54. What is plexiform neurofibromatosis?

55. What is Keloid?

56. Keloid Vs Hypertrophic scar.

57. Treatment of Keloid.