Examination of a lump

Examination of a lump is a component in almost every surgical clinical examination. Sometimes you may be asked to spot diagnose a lump with just inspection. Given below is a rough guide to examination of a lump.

Inspection

1. Site, Size and Shape (SSS).
2. Skin overlying the lump (Scars, Signs of Inflammation, Punctum).

Palpation

1. Surface (Smooth/Irregular).

2. Edge (Well or poorly defined).

3. Tissue Plane/ Mobility /Fixity - Skin attachment and attachment to underlying structures.

4. Consistency (Soft, Firm or Hard). 5. Cross Fluctuation (Only if soft to firm).

6. Transillumination (Only if fluctuant).

7. Temperature and Tenderness

8. Reducibility.

9. Pulsatility.

10. Palpable lymph nodes (If Applicable).

There is a hemispherical shaped lump, over the left lateral aspect of the neck, measuring 5cm x 5cm in size. The overlying skin looks normal. Its surface is smooth and the edge is well defined. It is mobile and not attached to skin or the underlying structures. It is soft in consistency, fluctuant and transilluminant. It is not reducible or pulsatile and there is no associated lymphadenopathy.

Tip: If you are confident enough, make sure that you give a rational presentation, excluding the possibilities one by one for more marks.

1. Site, Size, Shape, Skin and Surface.
2. Edge.
3. Tissue Plane.
4. Consistency. 5. Fluctuation.

6. Transillumination.
7. Reducibility.
8. Pulsatility.
9. Lymphadenopathy.

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1. How do you elicit the skin attachment of a lump?

Using the thumb of the examining hand, the skin over the lump is stretched in two directions perpendicular to each other. If the skin is freely movable over the lump, the lump is not attached to the skin

2. Why "pinching" the skin over the lump is not the ideal way?

This method is not accurate as the lump may be attached to the skin in a point other than the site of pinching.

3. How do you elicit fluctuations?

First the lump should be fixed between the two feeling fingers (the index finger and the thumb) of one hand and press on the lump using the index finger of the other hand. If you can see the feeling fingers moving apart with each press, it is fluctuant. The same technique of examination should be carried out twice in two directions perpendicular to each other, "Cross Fluctuations".

4. If it is fluctuant, what does that mean?

That means the lump is cystic: in other words, it contains fluid. But lipomas (fat cells) can show pseudo fluctuations.

5. If it is transilluminant, what does that mean?

That means the fluid inside is clear and does not absorb light. Some lumps are brilliantly transilluminant.