Learning_objectives

  • To be able to systematically examine and describe the characteristics of a swelling
  • To understand the difference between a true and false swelling
  • To be able to document your findings

Theory_and_background

The presentation of lumps, swellings or masses is a common clinical situation: 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 a number of characteristics that cannot in all cases be described e.g. the appearance and colour of the overlying skin can be described if examining a breast lump, but not if it is a mass found in the rectum.

This guide covers the examination of generic swellings, but please look at the individual study guides for details of specific (rectal, bimanual, breast etc) examinations.

Overview of swellings descriptors

When examining and describing swellings it has a modified version of inspection etc which is as follows Inspection, Initial palpation and then Palpation.

In terms of an overview a swelling can be described using the following descriptors;

Inspection

  • Position
  • Overlying skin

Initial palpation

  • Pulsation
  • Tenderness

Palpation

  • Mobility
  • Shape
  • Surface
  • Edge
  • Consistency
  • Depth
  • Indentation
  • Fluctuation
  • Temperature
  • Size
  • Transillumination

The above adjectives will be expanded on as you proceed through this study guide.

Terminology

Do not confuse pain with tenderness. The patient may have complained of pain in their history this would be classed as a symptom. Whereas, tenderness is a sign that is detected during the examination.

Patient safety.

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date of birth, if available please check this with the name band and  written documentation and the NHS/ hospital number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required, especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

This procedure may require the presence of a chaperone. That is someone who is familiar with the examination and can ensure that nothing inappropriate occurs by either party. The chaperone can be a useful resource, not just being present to ensure the patient is treated appropriately, but to help and support the patient.

Procedure

Inspection of the swelling

Inspect the patient from the end of the bed or when you first observe them and note any indication of pain, their gait and any other features that may deviate from the norm.

On closer observation ensure the patient’s dignity is maintained and expose as much as is necessary.

Observable features to note;

Position

  • Describe the position in detail. For example “A swelling was observed on the anterior aspect of the forearm, 10cm distal to the antecubital fossa”.

Because writing “There is a swelling just below the inside on the elbow carries insufficient precision of information.

The text that you write can be reinforced by a drawing denoting what you have written.

Overlying skin;

  • Where possible inspect the overlying skin of the swelling noting the colour of the swelling as well as that of the surrounding skin.
  • Note if there is any bleeding or evidence of sepsis (pus)
  • Note if the skin is intact or broken. There may be obvious puncture marks indicating an insect bite.

Palpation

When palpating you may detect that the swelling is pulsating, this may also be observed on inspection. However, you will need to palpate to determine the origin of the pulsation and whether it is tender or not.

Position 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 aneurysm (which may rupture if the examination is too rigorous).

If pulsation is felt; does it feel as if the pulsation is in all directions (‘true pulsation’) or simply ‘up and down’ (‘false pulsation’)?

If the mass is pulsatile, stop examining and ask a senior colleague to review the patient.

True pulsation

This is potentially the more serious condition as it means the swelling is in the wall of an artery i.e. an aneurysm. The nature of true pulsation is that the pulsation takes places in all directions of the vessel simultaneously.

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

Tenderness

When palpating the swelling observe the patient to note any signs of tenderness. If any tenderness is exhibited, then care must be taken in how you palpate to avoid further discomfort. If it is so tender, you may have to offer analgesia (pain relief) before carrying on with the exam.

The presence of tenderness may give you a clue as to the cause of the swelling. e.g. an abscess.

So far in the examination of a swelling we have looked at;

  • Position
  • Overlying the skin
  • Pulsation
  • Tenderness

A simple mnemonic to help remember these factors is: Pupils Only Play Tennis.

Shape

Describe the shape. You may wish to use the following adjectives;

  • spherical
  • elliptical
  • irregular shape
  • ovoid

Surface

Note what the surface texture of the swelling feels like and describe it as;

  • rough
  • smooth
  • granular
  • nodular

Edge

Following on from describing the surface, describe the edge or the borders of the swelling. You may wish to describe as follows;

  • “Clearly defined edge”.
  • “Clearly defined edge with nodules”.

If the edges are not clearly defined and you cannot determine the edges or the border of the swelling you would describe it as “Diffuse”. Describe as follows;

  • “Diffuse edge”.
  • “Edge diffuse”.

An example of why a swelling may be diffuse is oedema, so causing the edges to be diffuse or blurred.

Consistency

When you have palpated you may have noted and described the surface of the swelling, but how does it feel?

You may wish to describe it as follows;

  • “It is hard”.
  • “It is firm”.
  • “It is soft”.
  • “It is boggy”.

Depth

Swellings can be classed as either deep or superficial and this may indicate the origin of the swelling. For documentation purposes you may describe the swelling as a superficial swelling or a deep swelling.

This is not a measurement of the height of the swelling but as described, its origin.

For example;

  • A rectal mass would be classed as a deep swelling.
  • An insect bite on a finger that caused a swelling would be described as superficial.

Indenting of the swelling

Apply gentle pressure to the surface of the swelling with your examining index finger and note if there is a depression left on the surface of the swelling upon withdrawal. If there is then it can be described as indentable.

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.

Fluctuance

A swelling can be classed as either fluctuant or non-fluctuant. Fluctuance is where the swelling may contain fluid within and of varying viscosity. The fluid within the swelling can cause the fluid to move if pressure is exerted at specific points on the swelling’s surface. In other words is it “squidgy?”

This fluid may be clear or opaque e.g. blood or pus.

In order to test for this you may do the following;

  • 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.

Temperature

If the swelling is superficial and has a “red angry” appearance suggestive of infection, you may want to assess the temperature of the swelling by holding the dorsum (back) of your hand above its surface. Then compare that temperature to that of the surrounding tissues.

Document whether the swelling was;

  • hot
  • warm
  • cold
  • no temperature difference to that of the surrounding tissues

Size

Size is an obvious adjective when it comes to examining and documenting any swelling.

Size is measure in two dimensions – length x breadth and documented in centimetres or the appropriate S.I. unit.

When measuring a swelling place the ruler or measuring tape alongside the swelling and not over it as this would incorporate the height as well.

If you cannot measure it, then estimate it by palpation. For example an ovarian cyst.

To get some perspective on the measurement, it is not uncommon to equate it to a “lump of fruit” or another commonly recognisable object.

Transillumination

Some swellings may contain serous fluid which is clear. Therefore, when examining a swelling you may want to determine if that swelling is transilluminable. This will indicate whether the fluid in the swelling is clear or non-transilluminable e.g. blood or pus.

To test for this;

  • 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’.

Mnemonics

These mnemonics may help you to remember what you are looking for and what you should be noting on palpation.

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

 

Pick your favourite!

Documenting your findings

Document your findings as you would any other examination in the patient’s notes (see history taking study guide). Remembering to use a black pen as well as documenting your name which should be printed, your signature, date & time plus your role.

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.

Summary

On inspection check for;

  • position
  • overlying skin

Then;

pulsation & tenderness

Remember you can use the mnemonic of Pupils Only Play Tennis.

Then palpate for;

  • mobility
  • shape
  • surface
  • edge
  • consistency
  • depth
  • indentation
  • fluctuance
  • temperature
  • size
  • transillumination

View/download the examination of swellings study guide here