Swelling History - PDF

A ‘Lump’ is a vague mass of body tissue. A ‘Swelling’ is a vague term which denotes any enlargement or protuberance in the body due to any cause. According to cause, a swelling may be congenital, traumatic, inflammatory, neoplastic or miscellaneous. A ‘Tumour’ or ‘Neoplasm’ is a growth of new...

A ‘Lump’ is a vague mass of body tissue. A ‘Swelling’ is a vague term which denotes any enlargement or protuberance in the body due to any cause. According to cause, a swelling may be congenital, traumatic, inflammatory, neoplastic or miscellaneous. A ‘Tumour’ or ‘Neoplasm’ is a growth of new cells which proliferate independent of the need of the body. While benign tumour proliferates slowly with little evidence of mitosis and invasiveness to the surrounding tissues, malignant tumour proliferates fast with invasiveness and mitosis. HISTORY.— It is recorded as described in Chapter 1 with particular reference to the following points : 1. Duration.— ‘How long is the lump present there?’ That means, you should ask the patient, ‘When was the lump first noticed?’ In case of congenital swellings, e.g. cystic hygroma, meningocele, they are likely to be present since birth. One thing must be remembered that there is heaven and hell difference between ‘The lump was first noticed two months ago’ and ‘The lump first appeared two months ago’. The former is the patient's finding and very often they feel its existence later than it actually appeared. A painless lump may be present for a long time without the patient's knowledge. Fig.3.1.— Sacrococcygeal teratoma usually presents since birth. Rudimentary hand is seen in the tumour which develops from the totipotent cells. Figs.3.2 & 3.3.— Keloids have developed in the scars of vaccination and ear pricks. Lumps with shorter duration and pain are mostly inflammatory (acute), whereas those with longer duration and without pain are possibly neoplastic (benign). But the swellings with longer duration and with slight pain may be chronic inflammatory swellings whereas swellings with shorter duration may be neoplastic, mostly malignant.  2. Mode of onset.— ‘How did the swelling start’? It may have appeared just after a trauma (e.g. fractured displacement of the bone, dislocation of the joint or haematoma) or may have developed spontaneously and grown rapidly with severe pain (inflammation) or was noticed casually and the swelling was gradually increasing in size (neoplasm). Sometimes swelling may occur from pre-existing conditions, e.g. keloid may start from a scar of burn or otherwise (Fig.3.2) or even from a pin prick in the ear (Fig. 3.3). Malignant melanoma generally develops from a benign naevus or a birth mark. The neoplasms are mostly noticed casually and the patient says, ‘I felt it during washing’. Or ‘Someone else noticed it first and drew my attention.’ These swellings are more dangerous and should invite more careful examination than those which are painful and mostly inflammatory or traumatic. 3. Other symptoms associated with the lump.— PAIN is by far the most important symptom, which brings the patient to the doctor. Sometimes there may be other symptoms associated with the lump, such as difficulty in respiration, difficulty in swallowing, interfering with any movement, disfiguring etc. The patient will definitely give the history of pain, but he may not give the history of other symptoms. So he must be asked relevant questions to find out if any symptom is associated with the lump. 4. Pain.— Pain is an important and frequent complaint of traumatic and inflammatory swellings, whereas pain is conspicuously absent in neoplastic swellings particularly in early stage. If the patient complains of pain associated with the lump, the surgeon should know precisely its nature, site and time of onset — whether appeared before the swelling or after it.  Fig.3.4.— Keloids have developed from scars of healed boils. Nature of the pain.— Whether the pain is throbbing which suggests inflammation leading to suppuration; or burning; or stabbing i.e. the pain is sudden, sharp, severe and of short duration; or distending; or aching type. Site.— Sometimes the pain is referred to some other site than the affected one. As for example, in case of affection of the hip joint, the pain may be referred to the corresponding knee joint. But most often the pain is localized to the site of the swelling. Time of onset.— It is very important to know whether the pain preceded the swelling or the swelling preceded the pain. In the case of inflammation pain always appears before the swelling, but in case of tumours (both benign and malignant) swelling appears long before the patient will complain of pain. It cannot be impressed too strongly that most malignant tumours be it in the stomach, kidney, rectum or breast, are painless to start with. Pain only appears due to involvement of the nerves, deep infiltration, ulceration, fungation or associated inflammation and often indicates inoperability. The only exception is osteosarcoma in which mild pain is usually the first symptom and precedes the appearance of swelling.  5. Progress of the swelling.— ‘Has the lump changed its size since it was first noticed’? Benign growths grow in size very slowly and sometimes may remain static for a long time. Malignant tumours grow very quickly. Sometimes the swelling suddenly increases in size after remaining stationery for a long period — this suggests malignant transformation of a benign growth. If the swelling decreases in size — this suggests inflammatory lesion. The patient should also be asked whether he has noticed any change in the surface or in consistency of the swelling. 6. Exact site.— Mostly the site of the swelling is obvious on inspection. In case of a huge swelling, the surgeon may be confused from which structure the swelling appeared. In these instances the patient may help the surgeon by telling him the exact site from which the swelling originated. 7. Fever.— Enquiry must be made whether the patient ran temperature alongwith the swelling or not. This suggests inflammatory swelling. Abscess anywhere in the body may be associated with rise of body temperature — typical examples being axillary abscess, gluteal abscess, ischiorectal abscess etc. Pyogenic lymphadenitis is often associated with fever. Sometimes Hodgkin's disease, renal carcinoma etc. are also associated with peculiar fever. 8. Presence of other lumps.— ‘Whether the patient ever had or has any other lump’? Neurofibromatosis, diaphyseal aclasis etc. will always have multiple swellings. Similarly Hodgkin's disease generally shows multiple lymphoglandular enlargements. Abscesses may occur one after the other. 9. Secondary changes.— Some swellings present secondary changes such as softening, ulceration, fungation, inflammatory changes etc. The patients should be asked for the secondary changes specifically. 10. Impairment of function — particularly of the limb or spine may be associated with a swelling near about. Enquire about the nature of loss of movement and intensity of it and how much of it is due to the swelling. An osteosarcoma near knee joint may cause partial or total loss of knee movement. Similarly a cold abscess from caries spine will cause limitation of movement of the spine. Fig.3.5.— Multiple swellings of neurofibromatosis (Von Recklinghausen's disease). 11. Recurrence of the swelling.— If the swelling recurs after removal, this often indicates malignant change in a benign growth or the primary tumour was a malignant one. Certain other swellings are notoriously known to recur e.g. Paget's recurrent fibroid. Cystic swelling may recur if the cyst wall is not completely removed. 12. Loss of body weight.— Appearance of swelling may be associated with loss of body weight. This indicates that the swelling may be either a malignant growth or a cold abscess with generalized tuberculosis. 13. Past history.— This may reveal presence of similar swelling or recurrence of swelling. Past history of syphilis or tuberculosis may offer clue to the present swelling. 14. Personal history.— Habit of eating betel leaf, betel nut, slaked lime or tobacco, may be the aetiological factor for growth in the mouth, tongue, cheek or lip. ‘Chutta Cancer’ of hard palate is seen in women who smoke cigars with the burning ends in their mouths. ‘Khaini Cancer’ occurs due to mixture of lime and tobacco kept in the gingivolabial sulcus.