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 HISTORY AND EXAMINATION OF LUMPS AND ULCERS

HISTORY OF LUMPS:
1- when was the lump first noticed?  many have lumps for
months or years before they notice it.
2- What made the patient notice the lump?  the presence or
absence of pain is important because pain is usually
associated with inflammation not neoplasm.
3- What are the symptoms of the lump?  it could be painful or
disfiguring or interfering with movement, respiration, or
swallowing.
4- Has the lump changed since it was first noticed?  has it
gone bigger or smaller, or has it fluctuated in size and when
did they notice the change. Has changes in the nature of the
lump occurred as tenderness.
5- Does the lump ever disappear?  on lying down, or during
exercise and yet it could be irreducible at the time of
examination.
6- Has the patient ever had any other lumps?
7- What does the patient think caused the lump?

EXAMINATION:
1- the site
2- the color and texture of the overlying skin.
3- The shape three dimensions (eg: spherical not circle)
4- The size sometimes a diagram will clarify it.
5- The surface the first feature that is notices on examination,
it maybe smooth or irregular.
6- Temperature assessed by the dorsum of the fingures.
7- Tenderness
8- Edges either clearly defined or indistinct.
9- Composition
a- calcified tissues such as bonehard
b- tightly packed cellssolid
c- extravascular fluid such as urine, serum, CSF, synovial
fluid, blood cystic
d- gas
e- intravascular blood
*the physical signs which help you define the composition of a
lump are:

1-consistence can vary from very soft to very hard

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 a- stony hard not indentable like bone or calcification
b-firm hard but not as hard as bone
c-rubbery slightly squashable like a rubber ball
d-spongy soft and very squashable but with some resilience
e-soft squashable with no resilience
the consistence of a lump depends not only on the structure but
also on the tension within it.

2-fluctuation pressure on one side of a fluid filled cavity makes

the other surfaces protrude.
-It can only be elicited by feeling at least two other areas of the
lump while pressing on a third.
-This exam is best done in two directions, the second at right angle
to the first.

3-fluid thrill a percussion wave is easily conducted across a large

fluid collection –cyst- but not across a solid mass.

4-transillumination light will pass easily through clear fluid but not
through solid tissues.
-fluids that transilluminate are water, serum, lymph or plasma or
highly refractile fat.
-transillumination requires a bright pinpoint light source and a dark
room.

5-resonace solid and fluid filled lumps sound dull when

percussed. A gas filled lump sound hollow and resonant.

6-pulsatility lumps may pulsate because they are near to an

artery and are moved by its pulsations.
-expansile pulsations if the two fingers are pushed outwards and
upwards. Eg: aneurysm and very vascular tumors.
-transmitted pulsations if the two fingers move in the same
direction.

7-compressibility it is a feature of very vascular malformations

and fluid collections. A lump that is reducible such as a hernia can
be pushed away into another place but will often reappear
spontaneously without the stimulus of coughing or gravity.

8-bruits vascular lumps with AV fistulas can have a systolic bruit.

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9-reducibility lumps can be reduced by gentle compression. If
the lump reappears as the patient coughs, this is called cough
impulse and is a feature of hernia.

10-relations to the surrounding structures

-lumps attached to bone move very little.
- lumps attached to vessels or nerves move sideways not up
and down
-lumps in the abdomen arising from mesentry or omentum
moves freely

11-state of the regional lymph glands

12-state of the local tissue skin, SC, bone, muscle, local

circulation and nerve supply.

13-general examination always examine the whole patient.

 hints to remember the examination method:

 5S: site, size, shape, surface, state of surrounding
tissue and LN.
 3C: composition-and all the points under it described
above, color, cough impulse
 2R: reducibility, relation to surroundings.
 2T: temperature, tenderness.

DDx of lumps:
1-skin: sebaceous cyst, dermoid cyst, furuncle, carbuncle,
hidradenitis suppurtina.
2-under the skin: LN, lipoma, fibroma
3-nerves: neuroma
4-BV: angioma, aneurysm, AVM
5-soft tissue: fibrosarcoma
6-muscle: myosarcoma: 1-leiomyosarcoma 2-rhabdomysarcoma
7-bones: osteosarcoma, chondrosarcoma
8-swelling near the joints: ganglion, bursae, cystic production of
the synovial cavity of the arthritic joints.

 you have to look up all of these structures.

INVESTIGATIONS:
US: cystic or solid, Biopsy, FNA, CxR

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HISTORY OF ULCERS:
an ulcer is a solution or a break of the continuity of an epithelium
(i.e. an epithelial deficit, not a wound). Unless it is painless and in
an inaccessible part of the body, patients notice ulcers from the
moment they begin and will know a great deal about their clinical
features.
The history taking is the exact same thing done as when taking the
history of a lump – mentioned above-

EXAMINATION OF ULCERS: it follows the same pattern as

above plus the following:

1-base: the base or floor of an ulcers usually consists of slough or

granulation tissue but also bones or tendons may be visible. The
nature of the floor may give some indication of the cause:
*solid brown or grey dead tissue full thickness skin death

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*yellow grey wash leather slough syphilitic ulcers.
*bluish unhealthy granulation tissue tuberculous ulcers
*poor granulation tissue with tendons or other structures that may
lie bare in the base ischemic ulcers.

The redness of the granulation tissue reflects the underlying

vascularity and indicates the ability of the ulcer to heal. Healing
epidermis is seen as a pale layer extending in over the granulation
tissue from the edge of the ulcer.

2-edge: there are 5 types of edges

*a flat, gently sloping edge shallow, superficial ulcer. Mostly
venous ulcers. This healing ulcer has a pale pink almost
transparent edge.

*a square-cut or punched out edge rapid death and loss of whole

thickness of the skin without attempts to repair. This happens in
tertiary syphilis, neuropathic lesions of DM or ischemia and
leprosy. Mostly occur in the legs.

*an undermined edge infection of an ulcer involving the SC

tissue more the skin. Mostly happens in the buttock area. Happens
in tubercoulus ulcers.

*a rolled edge slow growth of the tissue in the edge of the ulcer.
Diagnostic of rodent ulcers – BCC- where telangiectases are seen
in the pearly edges.
*an everted edge the tissue in the edge of the ulcer is rapidly
growing that it spills out of the ulcer to overlap the normal skin.
This is typical of carcinoma.

3-depth
4-discharge serous, sanguinous, serosanguinous or purulent.

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CAUSES OF LEG ULCERS :

1-venous stasis ulcer most common

Site : around malleali
Associated pigmentation, stasis, eczema

2-ischemic ulcers:

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*large artery disease (atherosclerosis, obliterations) usually lateral
side of the leg with an absent pulse.
*small vessel disease

3-malignant ulcer: BCC, Sq.CC.

4-infections

5-neuropathic : painless penetrating ulcer on the sole of foot

6-underlying systemic disease:

*DM: vascular disease, neuropathy or necrobiosis lipodica (front of
leg)
*pyoderma gangrenosum
*rheumatoid arthritis
*lymphoma
*haemolytic anemia (small ulcers over the malleoli) as in SCA

INVESTIGATIONS:
1-fasting B.S. and R.B.S.
2-urin analysis
3-CBC
4-plain X-ray
5- swap for culture.
6-Biobsy for malignancy. It is taken from the edge of the ulcer.
7-arterio and angiogram.

MANAGEMENT:
clean the wound, dressing, Ab, skin grafting.
COMPLICATIONS OF ULCERS:
1-keloid: hypertrophic persistence scar
2-hypertrophic scar
3-hyper- or hypo – pigmentation
4- chronic benign ulcer sq. cc

NB: you have to read about ulcers of the ischemic, venous or

neuropathic eitiology and differentiate between them.

NB: you can refer to BROWSE’S book chapter one in the 4th
edition.

,,,,‫وهللا ولي التوفيق‬

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‫مالك الشمري‬

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