Palpable Masses, Lumps & Bumps Flashcards
Where are some common lumps?
Neck
Groin
Assorted (e.g. areas of hairy skin, trauma & self-inflicted like vagal head)
What could a right sided neck lump be?
Lymph node OR common carotid aneurysm OR embryological remnant of neck
Where is a hairy area of skin that commonly acquires abscesses?
Intergluteal cleft (not bum crack but just above it)
Why can lymph nodes enlarge and how can you tell the difference between causation?
Metastatic cancer: develops gradually long-term
Infection: develops quickly, might be red
BOTH may have other symptoms associated but these will be different
What are some weak regions in supporting tissues?
Inguinal canal
Pharyngeal pouches
What problems can occur in the development of the thyroid gland?
Embryological remnants as it descends from the mouth to the neck:
- Thyroglossal duct cyst: lump in anterior midline of neck and move on swallowing/tongue protrustion
- Lingual thyroid: foramen caecum (anterior and posterior tongue meet) remnant left behind that looks vascular and bleeds like a cancer
When does the thyroid gland move?
During swallowing but not always with tongue protrusion
What should you ask in a history of presenting complaint of a lump?
- How long have you had this?
- Is it painful or do you have pain elsewhere?
- History of trauma?
- Any previous or recent treatment/intervention/surgery?
- Site-dependent questions
- Neurological disturbance i.e. tingling? numbness?
- Temporally-associated systemic symptoms?
What additional factors should you consider when forming a diagnosis of a lump?
Demographics:
- Age
- Sex
- Social history
- Occupation
- Medical history
If you draw out a pro-forma prior to examination/history taking what must you ALWAYS do first?
Tell the patient what you are doing!
How should you examine a patient with a lump?
- Introduce self and check patient details along with hand cleaning
- Gain informed consent and tell patient what you are doing, why and what you expect throughout as well
- Inspect, palpate, percuss + auscultate
- Explain findings to patient, thank them + end consultation
What types of noises may you hear in a lump?
Bowel sounds
Bruits/vessel sounds
Lung sounds
Crepites
What must you look for in an examination of a lump?
S: Size, Shape + Surface P: Position A: Attachments C: Consistency + Colour E: Edges
P: Pulsation/thrills/fluctuance
I: Inflammation
T: Transillumination
What would you expect to find if a lump has fluid in it?
If will be soft
It will illuminate if a torch is taken to it
Fluctuance
What type of language is used to describe lumps?
Annular = ring-shaped Arcuate = curved Nodule/papule = palpable mass of specific size Macule = flat region of surface colour change Pustule = small pocket of pus
How can you tell what layer of a system a lump is in?
If it is associated with skin it will move with skin whereas if it is deep to it, it may still move but the skin would move freely over it, it would not be bound to the skin
What types of lumps are found in the skin?
Epidermoid cyst
Papilloma
What types of masses can move and how will they move?
Bone: hard and immobile and will not move independently ONLY with the bone
Muscle/tendon: moved by/have their movement limited by muscle contraction
Neural: medial-lateral
What finding would you expect if a mass is neural in nature?
Pain/tingling/sensory loss
What types of skin tumours can present as lumps?
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
What types of observations would you make to determine if a lump is cancerous or not?
A: Asymmetry
B: Borders
C: Colour
D: Dimensions
How would lymphadenopathy present?
Palpable relatively non-mobile mass and most commonly unilaterally in positions where main lymph node groups are
What pattern do lymph nodes of the neck follow?
Follow base of the mandible and skull:
- Lateral tongue and mandibular teeth drain into submandibular lymph node
- Upper limb, breast tissue, thoracic wall, proximal foregut and upper lobe of L lung into supraclavicular lymph node
Why might patients present with unusual masses?
Regional lymph node drainage AND embryology e.g. bladder cancer can present with a lump in umbilicus (Sister Mary Joseph nodule) due to the urachus (remnant of allantois)
When lumps occur in the groin/scrotal region, what must be considered?
- Can you get above the swelling?
- Reduce a hernia and test cough impulse
- Is it solid/fluid-filled?
- Where is lump relative to testicle?
- Can you find the testicle?
- Does it feel/look like a bag of worms?
Why should you check if you can get above a scrotal/groin swelling?
If YES: not a hernia if can feel the spermatic cord
If NO: most likely a hernia if everytime you push it, it disappears into abdominal wall so can never get finger above it
What should always be assumed about testicular pain at first? Why?
Its TORSION - if testicle rotates on blood supply cutting it off, it will die very quickly and causes a lot of pain
What are the different types of scrotal swellings?
- Inguinal hernia: descend into testicle from abdomen
- Hydrocele: fluid-filled lump covering testicle completely
- Varicocele: venous swelling around spermatic cord (bag of worms)
- Testicular cancer: firm lump around testicle but can feel testicle
- Spermatocele/epididymal cyst: fluid-filled bag superior to testicle not around it
What scrotal swellings would you get your hand above?
Hydrocele
Spermatocele
Varicocele
How does a patent processus vaginalis present?
Scrotal swelling that appears when patient is stood up due to gravity and disappears when laid down (like an inguinal hernia), it will transluminate (like hydrocele) but you cannot get your hand above the swelling
What is patent processus vaginalis?
When testicle descends through abdominal wall, it pulls a loop of peritoneum with it and most of this loop will become fibrotic however, if it stays open, peritoneal fluid from the abdominal cavity can end up herniating through the scrotum
What types of hernias exist?
Inguinal Femoral Incisional (post-operative) Umbilical Lumbar (superior and inferior)
What should you exam when looking at a possible inguinal hernia in Hesselbach’s triangle?
Patient lying down/standing Observe site and direction Make other regional obs Compare side Test cough impulse Is it reducible? Pressure over alternate inguinal rings May need to stand Auscultate for bowel sounds
What types of groin swellings can occur in females?
Femoral
Canal of Nuck (embryological remnant)
Bartholin gland cyst
What are the borders of the femoral triangle?
Inguinal ligament (from ASIS to pubic tubercle), sartorius and adductor longus
What is the route of femoral vessels and salphenous nerve?
Enter subsartorial/adductor canal and pass into popliteal fossa
How can you tell the difference between a femoral and inguinal hernia?
Femoral hernias are lateral and inferior to pubic tubercle inguinal hernias are lateral and superior to pubic tubercle
What is saphena varix?
Saphenous veins pierce the roof of the femoral triangle and can dilate causing varicosities to appear at saphenous opening
What route do femoral hernias take?
Via saphenous opening with inguinal lymph node drainage (lower limb lymphatics drains into pelvic/abdominal regions via this)
Where is the femoral artery?
Enters between midinguinal point and midpoint of inguinal ligament
Where are the superficial inguinal lymph nodes?
Proximal and distal to pubic tubercle
What is the femoral sheath?
Fascia layer bound to outer wall of artery and veins around the vessels in the femoral triangle meaning nothing can pass through abdomen to here but lymphatics are not tightly bound to it - femoral nerve lies outside of sheath and deep to iliac fascia
What is the femoral canal Whats its clinical significance?
Fascial compartment accessed through femoral ring for lymphatics but it does not bind to lymphatics representing a weak spot for abdominal hernias -contains lymph vessels and prominent lymph nodes e.g. Cloquet’s
What makes up the femoral ring? What is the clinical significance of this?
Lacunar, inguinal and pectineal ligament and there is a rigid bone border meaning hernial hernias are likely to undergo strangulation and cut off its own blood supply as its irreducible
What is an unusual cause of a femoral hernia?
Ectopic ascites associated with cirrhosis from the abdomen has travelled down the femoral canal into the femoral ring
