Abnormal features

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Position. The site of some swellings such as those in the breast, the thyroid or the parotid glands presents no difficulty. In others, the ease with which the lump can be localised will vary, especially in the abdomen. Features such as shape or mobility may help to identify the anatomical origin and occasionally percussion may also help in defining an abdominal mass.

Size. The size of any swelling requires to be accurately measured and documented. In this way significant changes can be recognised. Vague and misleading statements about size, such as large, medium or small, or comparisons with fruit, eggs or vegetables should be avoided.

Shape. The shape of a mass may be sufficiently characteristic to signify its origin. Examples in the abdomen include an enlarged spleen or liver, a distended bladder or the fundus of the uterus in later pregnancy.

Temperature and colour. The skin over acute inflammatory lesions is usually red and warm. There may also be a rise in skin temperature over a vascular tumour which ranges in colour from red to blue or purple according to the proportions of reduced haemoglobin present and the depth of the layer of skin through which it is seen. In haetriatomas the pigment from cxtravasatcd blood may produce the range of colours so familiar in a bruise. A brown or black colour is common in melanomas (Fig. 2.21. p. 44). though some are not pigmented. A xanthoma is a small skin nodule which may be identified by its yellow colour because of the lipids it contains.

Pain and tenderness. Inflammatory swellings are characterised by tenderness. Some other swellings, such as large lipomas, may be entirely free from pain or tenderness, because they carry no nerve supply and have developed in an area where the mass can be accommodated without subjecting any structure to undue stretching. Tumours eroding bone or growing into nerve roots and plexuses cause severe persistent and intractable pain which is often worse at night.

Movement. A mass may be part of. attached to. or free from adjacent structures, such as skin or bone. Fixation of the skin may be associated with a fine dimpling at the opening of the hair follicles resembling an orange skin when there is lymphatic obstruction ('peatt d'orange'). Such a change is most commonly due to malignant disease. Fixation to deeper structures may occur. For example, a breast tumour may become fixed to underlying muscle.

The presence or absence of movement on swallowing, respiration and coughing will produce information regarding the nature of the swelling in the ncck (p. 62), abdomen (p. 162) and hernial orifices (p. 163) respectively.

Hxpansile pulsations arise from aneurysmal dilatation of the aorta or other large arteries, or highly vascular tumours. A transmitted pulsation may be detected if a mass is in contact with a major blood vessel. In tricuspid incompetence, the liver is pulsatile.

Consistency. The consistency of a swelling may vary from soft and fluctuant through increasing degrees of firmness until this may merit the term "stony hard'. Very hard swellings are usually malignant or calcified, or consist of dense fibrous tissue.

Fluctuation indicates a fluid-containing swelling, such as an absccss or a cyst. Soft encapsulated tumours such as lipomas may also show some degree of fluctuation.

Surface texture. The surface of a swelling may vary from the uniformly smooth to the grossly irregular. The texture often provides important evidence of the pathological process. For example, on palpation of the liver the surface is smooth in acute right ventricular failure but is usually grossly nodular in metastatic malignancy.

Margin. The edge or margin may be well delineated or ill defined, regular or irregular, sharp or rounded. The margins

Fig. 2.41 Neurofibromatosis.

of enlarged organs such as the thyroid gland, iivcr. spleen or kidney can usually be defined more clearly than those of inflammatory or malignant masses. An indefinite margin may suggest an infiltrating malignancy in contrasl to ihc clearly defined edge of a benign tumour.

Associated swellings. Conditions in which multiple swellings occur include neurofibromatosis (Fig. 2.41), lipomatosis, metastases in the skin, lymph nodes in the lymphomas and fibrocystic changes in the breast. If there is suspicion that a tumour is malignant, the lymph nodes draining the area concerned should be thoroughly examined.

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