CLERKING OF A LUMP/SWELLING
A. Biodata
B. History to be taken from the patient- Site of the lump e.g. neck swelling, axillary, groin swelling
- When it was first noticed (i.e. duration of the lump)
- How it was noticed
- Progression of the lump:
- Does it increase rapidly?
- Does it increase slowly?
- Does it remain static?
- Does it decrease in size
- History of associated symptoms such as
- Pain
- Discharge,
- Bleeding and
- Ulceration on the swelling/lump
- History of possible aetiological factors (TINCABED)/predisposing factors e.g
- Colorectal cancer- positive family history, dietary history
- Breast cancer- positive family history, history of contraceptive use.
- History of possible complications e.g.
- Pressure effect of colorectal cancer - diarrhea, constipation; frequency, urgency, respiratory difficulty etc.
- Pressure effect of breast lesion on the axilla: swelling of the affected limb.
- Others are- asthenia, anorexia, features of anaemia and ulceration etc in cases of malignancies
- History of care given so far: these include;
- Care given at home
- Other hospitals and
- Treatment in the hospital since admission till clerking.
EXAMINATION OF A LUMP
Expose the patient adequately after taking consent.A. Inspection
- Single or multiple lumps
- Site of the lump
- Shape of the lump
- Surface of the lump; presence of
- Scars
- Sinuses
- Ulcers e.t.c
- Surroundings of the lump; presence of dilated veins
- Site specific signs e.g.
- Cough impulse for inguinal or anterior abdominal mass
- Movement with protrusion of the tongue for anterior neck mass.
B. Palpation
- - Temperature/differential warmth:
- Palpate 3 times starting and ending with a normal site
- Tenderness
- Size; in 3 dimensions
- Topography
- Surface:
- Lobulated
- Nodular
- Smooth,
- Surrounding
- Consistency:
- Soft,
- Firm
- Hard
- Mixed consistency
- Edge
- Well defined
- Ill defined
- Indurated
- Indentation: apply a sustained digital pressure on a firm swelling e.g. of indentable masses are
- Large dermoid cyst
- Large sebaceous cyst and
- Feacoloma
- Fluctuancy: use the index finger of one hand as displacing finger and both of the thumb and index finger of the other hand as watching fingers. Check at two angles, 90 degrees apart.
- Fluctuancy is only demonstrated in soft swellings. A soft lump <2 cm in size may not be fluctuant. A lipoma (not a soft mass) may be fluctuant at a high temperature.
- Once you elicit for fluctuancy, you must transluminate the mass. Place a cone on the mass opposite the light source in a straight line. (A cone is not necessary in a dark room).
- Examples of masses that transluminate brilliantly include;
- Cystic hygroma
- Vaginal hydrocele
- Encysted hydrocele of the cord
- Hydrocele of the canal of nuck
- Spinal meningocele
- Ranula
- N.B
- A long standing hydrocele may not transluminate due to infection, hemorrhage or calcification.
- Inguino-scrotal hernia in a child may transluminate because of the thin bowel wall.
- Pulsatility of the mass (know the types): Place the two index fingers on opposite sides of the lump and see if the fingers move.
- Vascular thrill: place the index and middle fingers on the mass to feel for a thrill (if positive then a bruit must also be heard on auscultation)
- Compressibility: Swelling disappears with pressure spontaneously but re-appears on withdrawal of the pressure.
- Reducibility: swelling disappears with the pressure but re-appears when induced by coughing or straining.
- Movement: pinch the skin over the lump; move the lump in 2 planes at right angle to each other.
C. Percussion
- Done only for abdomen and chest
D. Auscultation
- Vascular bruit over the lumps
- Bowel sounds for abdominal masses.
References
2. (1998). Browse's introduction to the symptoms and signs of surgical disease / Norman L. Browse [and others]. (4th). London: Arnold.
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