Examination of a lump

Question 1

Features to characterise a lump.

a) Inspection (5)
b) Palpation (5)
c) Percussion (1)
d) Auscultation (1)
e) Special tests
f) Should also examine what…?

Answer 1

a) Inspection.
- Site - anterior, posterior triangle, etc.
- Size - use tape measure, or distal phalanx of index finger (~ 2.5 cm) for reference
- Shape - round, irregular, etc.
- Colour - erythematous or same as surrounding skin
- Contour - appearance of overlying skin

b) Palpation.
- Tenderness
- Temperature
- Tethering - freely mobile, or tethered to overlying skin or underlying muscle?
- Consistency - hard (forehead), firm (tip of nose), soft (lips)
- Pulsatility - suggests aneurysm (thrill - fistula)

c) Percussion.
- Resonant - suggests gas (eg. loop of bowel)
- Dull - suggests solid (eg. malignant nodule) or fluid (eg. enlarged bladder)
- (note: often of limited value)

d) Auscultation.
- Bruit - suggests aneurysm
- Bowel sounds - suggests bowel (eg. hernia)

e) - Moves with tongue protrusion (?thyroglossal cyst)
- Moves with swallowing (?thyroid swelling/thyroglossal cyst)
- Compressibility/fluctuation - ?varicosity
- ?transillumination - suggests cystic swelling

f) - Regional lymph nodes
- Relevant regional examination (eg. abdominal examination for an abdominal lump)
- General examination for other lesions, organomegaly, systemic illness (eg. jaundice, anaemia, bruising), etc.

Question 2

Hernias - features

Answer 2

• Reducible
• Cough impulse
• Usually soft
• Increases in size when asked to sit up

Question 3

Aneurysm - features

Answer 3

• Pulsatile
• ?usually soft
• ?bruit

Question 4

Summarise the findings of an uncomplicated 3 cm para-umbilical hernia with classic hernia features in Mr X, a 65 year old male

• Inspection
• Palpation
• Auscultation
• Special tests
• In summary

Answer 4

On examination of Mr X, a 65 year old male…

• A lump was found in the para-umbilical region (SITE), which measured around 3 cm (SIZE) and was round in SHAPE. The COLOUR and CONTOUR were the same as the surrounding skin
• On palpation, the lump was non-TENDER and normal TEMPERATURE, with no TETHERING to overlying skin. It was soft in CONSISTENCY, and non-pulsatile.
• There was no audible BRUIT but bowel sounds were auscultated
• The lump was REDUCIBLE, there was a positive COUGH IMPULSE and it enlarged when the abdominal wall was tensed
• In summary, this 3 cm para-umbilical lump with a positive cough impulse and reducibility is likely to be a hernia

Question 5

Hernia vs. divarication of the recti

Answer 5

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