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Examination of swellings

2. 10/26/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 2
Common features
 The presentation of lumps, swellings or masses is a
common clinical situtation (e.g. breast lump, swollen
ankles or a mass found on rectal examination).
 Most swellings can be described by a number of
common characteristics (e.g. size, shape, position etc).
However, there are some characteristics that cannot be
described in all cases (e.g. the state and colour of the
overlying skin can be described if examining a breast
lump, but not if a mass is found in the rectum).
 This guide covers the examination of a generic swelling,
but please look at the individual study guides for details
of specific (rectal, bimanual, breast etc) examinations.

3. Overview of swelling descriptors
INSPECTION:
 Position
 Overlying skin
INITIAL PALPATION:
 Pulsation
 Tenderness
PALPATION:
 Mobility
 Shape
 Surface
 Edge
 Consistency
 Depth
 Indentation
 Fluctuation
 Temperature
 Size
 Transillumination
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4. Introduction
 As always, it is important to introduce yourself and
your status to the patient.
 Check the patient‟s identity (name and D.O.B.).
 Explain what you plan to do during the examination.
 Gain consent for the examination.
 Wash your hands using the Ayliffe technique.
 Gloves if appropriate (e.g. „internal‟ examinations
such as rectal, or superficial swellings with
evidence of bleeding or infection).
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5. Inspection
 A general inspection of the patient (from the
end of the bed) is appropriate (e.g. are they
in pain?)
 Ensure adequate exposure of area to be
examined (whilst maintaining dignity).
 There are 2 points to note during inspection.
These are Position and the Overlying skin.
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6. Position
 Describe the position of the swelling in detail.
 For example, „on the anterior aspect of the
left forearm, 10cm distal to the antecubital
fossa‟
 Simply writing „on arm‟ would not be
sufficient to distinguish between a swelling
on the left wrist or one on the right shoulder!
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7. Overlying skin
 Inspect the overlying skin (if possible).
 Is it different in colour to the surrounding
skin? (red, bruised etc?)
 Is there pus or blood leaking from the
swelling?
 Is the skin broken or intact? (e.g. an insect
bite can have an obvious puncture mark in
the centre)
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8. Palpation
 Palpation is the next stage in the
examination of a swelling.
 There are 2 aspects of palpation that need to
be assessed carefully first.
 This initial palpation includes checking for
Pulsation and Tenderness.
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9. Pulsation
 With your hands on each side of the swelling, so that
your index fingers are gently resting on each side of
the swelling, note whether the mass feels pulsatile.
 If the swelling is pulsatile, it may suggest an aneursym
(which may rupture if examination is too rigorous).
 If a pulsation is felt; does it feel as if the pulsation is in
all directions („true pulsation‟) or simply „up and down‟
(„false pulsation‟)? (see next slide)
 If the mass is pulsatile, stop examining and ask a
senior colleague to review the patient.
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10. 10/26/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 10
True versus false pulsation
 True pulsation occurs
both up and down and
outwards
 False pulsation occurs
only up and down; the
mass sits on top of the
artery, but does not
distend outwards as it
does not transmit the
pressure wave caused by
the flow of blood
X X

11. Tenderness
 Is the swelling tender to touch? If so, extra care
will have to be taken during the examination to
avoid unnecessary discomfort.
 The presence or absence of tenderness will
also give you a clue to the cause of the swelling
(e.g. an abscess is usually tender)
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12. Terminology
NOTE:
 Do not confuse pain and tenderness.
 The patient may have complained of pain
during the history (therefore pain is a
symptom).
 Tenderness is a sign that is detected during
examination.
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13. So far…
INSPECTION & INITIAL PALPATION:
 So far, we have assessed 4 components of
the swelling.
 These are: Position, Overlying skin, Pulsation
and Tenderness
 If you need a mnemonic to help you
remember these, then you can use:
Pupils Only Play Tennis
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14. Palpation
 Palpate the mass methodically using the pulps of your
fingertips +/- thumb, and ensuring that you examine all
areas of the lump.
 From your palpation, you should be able to describe:
Mobility, shape, surface, edge, consistency, depth,
whether you can leave an indentation, whether the
swelling is fluctuant, temperature, size, and whether the
swelling transilluminates.
 The order of these elements may depend on the swelling
being examined. However, for most superficial
swellings, the given order would be appropriate.
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15. Mobile or non-mobile
To assess mobility:
 Hold the swelling between thumb and index
finger if possible and gently attempt to move
the swelling.
 Is the swelling mobile or non-mobile (fixed)?
 If mobile, does it move with manipulation or
movement of underlying structures, e.g.
respiration
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16. Shape
 Describe the shape of the mass.
 Is it spherical? Elliptical? Irregular shape?
Ovoid etc?
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17. Surface
 What does the surface of the swelling feel
like?
 Rough?
 Smooth?
 Granular?
 Nodular?
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18. Edge
 Is the edge defined (can feel it is clearly distinct
from surrounding tissues)? Document as “Clearly
defined edge”.
 You may wish to go on to describe the edge further
e.g. “clearly defined edge with nodules present ”
 If the edge is not clearly defined, it is termed
„diffuse‟. This means the edge is not clearly
identifiable (e.g. oedema). Document as “Diffuse
edge” or “Edge diffuse”
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19. Consistency
 How does the swelling feel when you palpate
it? (we have already described the surface,
but this is the consistency of the entire
swelling)
 Is it hard?
 Firm?
 Soft?
 Tense?
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20. Depth
 The depth of a swelling depends on cause of the
swelling.
 It is documented as either “Superficial swelling” or
“Deep swelling”.
 The depth is NOT the measurement of the height of
the swelling.
 A rectal mass would be an example of a deep
swelling.
 An insect bite on the finger would be an example of
a superficial swelling.
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21. Does the swelling indent?
 Apply gentle pressure to the swelling with your index
finger.
 Is there a depression left in swelling when pressure
applied is removed? If so, then the „swelling indents‟ or
you are „able to indent swelling‟.
 This is characteristic of oedema and faeces.
 NOTE: If the swelling indents when you press, but
springs back when your finger is removed, this IS NOT
indentation.
 WARNING - do not try to indent a pulsating swelling
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Fluctuant or non-fluctuant
 Two digits are placed either side
of the apex of the swelling
 Pressure is applied to the apex
 This is repeated with the digits at
90°
 The finding is positive if the two
digits are pushed away in both
directions
 If a swelling is fluctuant, it
suggests the presence of fluid
within the swelling.

23. Temperature
 If the swelling is superficial, it is often best to
feel the swelling with the back of your hand
to assess the temperature.
 Compare it to the surrounding tissues.
 Is the swelling hot, warm or cold compared to
the surrounding tissues? Or is there „no
temperature difference to surrounding
tissues‟?
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24. Size
 Size should be measured in two dimensions
(length x breadth) in centimetres.
 Use a ruler or measuring tape along side the
swelling (so as not to incorporate the height
of a swelling in to the measurement).
 If this isn‟t possible (e.g. palpation
of the ovary) then estimate or
describe as an object (e.g.size of an orange)
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Transillumination
 Shine a (cold) bright light
source against one side of
the swelling.
 Room may need to be
darkened, or a blanket or
tube of paper may be used.
 Light seen emerging from
the other side is termed as
„transillumination‟.
 Transillumination confirms
air or clear fluid within lump.
Document as:
„Swelling transilluminates‟
or „swelling does not
transilluminate‟.

26. Summary of swelling examination - I
Firstly perform INSPECTION:
 Check for Position and Overlying skin
Then check for:
 Pulsation and Tenderness
 (Remember these steps using mnemonic: Pupils
only play tennis)
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27. Summary of swelling examination - II
Then PALPATE for:
1. Mobility
2. Shape
3. Surface
4. Edge
5. Consistency
6. Depth
7. Indentation
8. Fluctuation
9. Temperature
10. Size
11. Transillumination
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28. Mnemonics
Here are some mnemonics to help you remember palpation of
a swelling (if you need it!) Just pick your favourite:
 Medical Students Sitting Exams Can Dive If Forget The
Simple Things
 Medical Students Sing Every Christmas Day In Festive
Trousers Sounding Terrific!
 Methicillin Sensitive Staph Epidermidis Can Definitely Infect
Fingers, Toes, Scrotum & Testes
 Men Secretly Starting Exercise Can Do It For Ten Seconds
Together
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Recording your findings
 Document your findings as you would any examination in
the patient‟s notes (see history taking study guide).
 Use black pen.
 Patient identified correctly, date & time (24hour)
 If you have taken a history from the patient, document the
history as usual. However, if you have not taken a history
DO NOT fabricate one!
 Document your examination findings. All 15 descriptors may
not be relevant for deep swellings, but it is usually possible
to note size, position, shape, consistency, surface & mobility
 A diagram may often be used.
 Sign and print your name at the end of the record.