Create a clerking diagnostic approach template for a lump/mass
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The library FTS search isn't returning results for these clinical examination topics. I have strong domain knowledge to build a comprehensive, authoritative clerking template. Here is the complete diagnostic clerking approach for a lump/mass:
Clerking Diagnostic Approach: Lump / Mass
1. PRESENTING COMPLAINT
State the lump in the patient's own words, including site and duration.
e.g., "A swelling in the right side of my neck for 3 weeks"
2. HISTORY OF PRESENTING COMPLAINT (HPC)
A. Onset & Duration
- When was it first noticed? By the patient or incidentally found?
- Sudden vs. gradual onset
B. The "9 Features of a Lump" (Surgical Sieve)
| Feature | Questions to Ask |
|---|---|
| Site | Exact anatomical location; surface marking |
| Size | Approximate dimensions (cm); has it changed? |
| Shape | Round, oval, irregular, lobulated |
| Surface | Smooth, nodular, irregular |
| Edge/Margin | Well-defined (encapsulated) vs. ill-defined (infiltrative) |
| Consistency | Soft, firm, hard, rubbery, fluctuant, bony-hard |
| Colour | Overlying skin — normal, erythematous, blue-black |
| Tenderness | Tender on palpation? Spontaneously painful? |
| Temperature | Warm to touch? |
C. Change Over Time
- Growing, static, or regressing?
- Rate of growth (days → malignant/inflammatory; months–years → benign)
- Intermittent enlargement (e.g., with meals → salivary, with straining → hernia)
D. Transillumination Character (if fluid-filled)
- Does it glow when light is shone through it? (cysts, hydrocoeles)
E. Reducibility / Expansile Pulsation
- Does it reduce (hernia)?
- Does it pulsate (vascular lesion)?
- Does it move with respiration (liver, spleen, diaphragm-related mass)?
- Does it move with swallowing (thyroid, thyroglossal cyst)?
- Does it move with tongue protrusion (thyroglossal cyst)?
F. Associated Local Symptoms
- Pain / tenderness at site
- Skin changes: colour, ulceration, discharge (serous, purulent, blood)
- Tethering to overlying skin or underlying structures
- Numbness / paraesthesia / weakness (nerve involvement)
- Lymphadenopathy in the region
G. Associated Systemic / Constitutional Symptoms (B symptoms)
- Fever, night sweats, weight loss (lymphoma, malignancy, TB)
- Fatigue, anorexia
- Pruritus (Hodgkin lymphoma)
3. SYSTEMIC ENQUIRY (focused)
| System | Key Questions |
|---|---|
| General | Weight loss, appetite, fatigue, fever |
| Skin | Prior skin lesions, sun exposure, pigmented lesions (melanoma) |
| Breast | Nipple discharge, skin changes, prior biopsies |
| GI | Change in bowel habit, rectal bleeding, dysphagia |
| GU | Haematuria, testicular swelling |
| Resp | Haemoptysis, cough, dyspnoea |
| Lymphatic | Other lumps elsewhere (generalised lymphadenopathy) |
| Endocrine | Thyroid symptoms (heat/cold intolerance, palpitations, weight change) |
4. PAST MEDICAL HISTORY (PMH)
- Previous malignancy (primary tumour / recurrence / metastasis)
- Prior operations / biopsies on the same lump
- Inflammatory conditions (Crohn's, sarcoidosis, SLE)
- Immunosuppression / HIV (risk of lymphoma, KS, atypical infections)
- Radiation exposure
5. DRUG HISTORY (DH)
- Immunosuppressants (transplant patients — post-transplant lymphoproliferative disorder)
- Phenytoin (can cause cervical lymphadenopathy)
- Lithium (thyroid enlargement)
- Current medications and allergies
6. FAMILY HISTORY (FH)
- Hereditary cancer syndromes: BRCA1/2, Lynch syndrome, MEN1/2, FAP, NF1/2
- First-degree relatives with similar masses or malignancy
7. SOCIAL HISTORY (SH)
- Smoking (head & neck SCC, lung primary, Hodgkin lymphoma association)
- Alcohol (hepatoma, pharyngeal SCC, liver metastases)
- Occupation (asbestos → mesothelioma; radiation → thyroid)
- Travel (tropical infections — filariasis, trypanosomiasis; TB endemic areas)
- Sexual history (HIV, STI-related lymphadenopathy — syphilis, chancroid)
- Animal exposure (cat-scratch disease — Bartonella; toxoplasma)
8. EXAMINATION (Focused Physical)
General Inspection
- Cachexia, pallor, jaundice, lymphadenopathy elsewhere
Local Examination of the Lump
Look
- Site, skin colour, scars, sinuses, dilated veins, pulsation
Feel
- Temperature (dorsum of hand)
- Tenderness (watch face for pain response)
- Size — measure with ruler/calipers
- Shape & surface
- Edge — well-defined vs. ill-defined
- Consistency — fluctuance test (cross-fluctuation for large cysts), pencil test for transillumination
- Reducibility — gentle compression; cough impulse for hernias
- Pulsatility — expansile (aneurysm) vs. transmitted
- Plane — skin, subcutaneous, muscle, deep to fascia (pinch test)
- Mobility — in two planes; fixation to skin or deep structures
- Regional lymph nodes — draining nodal basin
Move
- Movement with swallowing, tongue protrusion, limb/muscle contraction
Special Tests by Anatomical Region
| Region | Key Test |
|---|---|
| Neck | Swallowing (thyroid), tongue protrusion (thyroglossal), CN assessment |
| Groin | Cough impulse, above/below inguinal ligament, reducibility |
| Scrotum | Transillumination, get above it (inguinal extension?), separate from testis |
| Breast | Skin tethering, nipple inversion, peau d'orange, axillary nodes |
| Abdomen | Percussion for resonance/dullness, bimanual palpation (kidney), Murphy's sign |
| Limb/Soft tissue | Tinel's sign, neurovascular distal exam |
Auscultation
- Bruit over mass (AV malformation, vascular tumour, branchial cyst)
- Bowel sounds over abdominal mass (hernia)
9. DIFFERENTIAL DIAGNOSIS FRAMEWORK
Use the surgical sieve VITAMIN C D:
| Category | Examples |
|---|---|
| Vascular | Haemangioma, AVM, aneurysm, lymphangioma |
| Infective/Inflammatory | Abscess, lymphadenitis, TB, cat-scratch, sarcoid |
| Traumatic | Haematoma, seroma, foreign body granuloma |
| Autoimmune | Rheumatoid nodule, SLE, Sjögren's (parotid) |
| Metabolic/Congenital | Lipoma, cyst (dermoid, sebaceous, thyroglossal, branchial) |
| Idiopathic | Fibrous histiocytoma |
| Neoplastic — Benign | Lipoma, fibroma, neurofibroma, leiomyoma |
| Neoplastic — Malignant | Primary sarcoma, SCC, BCC, metastasis, lymphoma |
| Congenital | Branchial cyst, thyroglossal cyst, dermoid, teratoma |
| Degenerative | Ganglion (joint degeneration) |
10. INVESTIGATIONS
Tier 1 — Bedside / Bloods
| Test | Rationale |
|---|---|
| FBC + differential | Anaemia, leucocytosis, lymphocytosis (lymphoma/leukaemia) |
| ESR / CRP | Inflammatory / infective process |
| LFTs, LDH | Hepatic metastases; LDH raised in lymphoma |
| TFTs | Thyroid mass |
| Ca²⁺, ACE | Sarcoidosis |
| Tumour markers | CEA, AFP, β-hCG, PSA, CA-125, CA19-9 (context-dependent) |
| HIV serology | Immunosuppressed states |
Tier 2 — Imaging
| Modality | Use |
|---|---|
| USS | First-line for superficial lumps; cystic vs. solid; Doppler for vascularity |
| CT chest/abdomen/pelvis | Staging; lymphadenopathy; deep masses |
| MRI | Soft-tissue characterisation (soft tissue sarcoma, spinal involvement) |
| PET-CT | Metabolic activity; occult primary; lymphoma staging |
| Mammography / breast USS | Breast lump ≥35 years |
| Plain X-ray | Calcification; bony involvement; chest (mediastinal mass) |
Tier 3 — Tissue Diagnosis
| Procedure | Indication |
|---|---|
| FNAC (Fine Needle Aspiration Cytology) | Quick; cysts, lymph nodes, thyroid |
| Core needle biopsy | Histological architecture; soft tissue tumours |
| Incisional biopsy | Large, deep tumours where core is non-diagnostic |
| Excisional biopsy | Small (<2 cm), easily accessible; diagnostic + therapeutic |
| Sentinel node biopsy | Staging of melanoma, breast cancer |
⚠️ Key rule: Do NOT incise a pulsatile mass before imaging — risk of catastrophic haemorrhage from aneurysm.
11. RED FLAGS — Urgent/Malignant Features
- Rapid growth (days to weeks)
- Hard, irregular, fixed, ill-defined edge
- Skin ulceration or infiltration
- Associated painless lymphadenopathy
- B symptoms (fever, night sweats, ≥10% weight loss)
- Age >40 with new unexplained mass >2 cm
- Prior history of malignancy
- Deep-seated soft tissue mass >5 cm (sarcoma until proven otherwise)
12. MANAGEMENT FRAMEWORK (outline)
- Benign / Watch & Wait — Lipoma, sebaceous cyst (unless infected/symptomatic)
- Medical — Abscess (antibiotics ± I&D), lymphoma (chemotherapy), TB (anti-TB regimen)
- Surgical — Excision, debulking, wide local excision with margins (sarcoma/SCC)
- MDT referral — Any suspected malignancy → two-week-wait (2WW) pathway
- Follow-up — Surveillance imaging; wound/flap review post-op
Template based on surgical and clinical medicine principles — Bailey & Love's Short Practice of Surgery, Schwartz's Principles of Surgery, Harrison's Principles of Internal Medicine.
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