Family medicine
Localised Lump
A localized lump is a discrete, palpable mass confined to a specific anatomical area, arising from abnormal growth or swelling of tissue such as a cyst, abscess, lipoma, or neoplasm.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Sebaceous (epidermoid) cyst | Punctum on surface, smooth, mobile, attached to skin [1] | 「上面有冇一個黑色細窿？」(any central punctum?) |
| Lipoma | Soft, lobulated, mobile, non-tender, subcutaneous, NOT attached to skin [1] | Palpation: soft, slippery, can pinch skin above freely | |
| Reactive lymph node | Recent infection, tender, mobile, < 1 cm, regresses | 「最近有冇病過、喉嚨痛或者傷風？」 | |
| Serious Not To Miss | Malignant lymph node (lymphoma / metastasis) | Hard, non-tender, fixed, > 2 cm, progressive, ± B-symptoms [2] | 「有冇瘦咗、出夜汗、發燒？」 |
| Breast cancer (if breast lump) | Hard, irregular, painless, skin tethering/peau d'orange, axillary LN [2] | 「皮膚有冇好似橙皮噉？有冇凹咗入去？」(dimpling / peau d'orange) | |
| Skin cancer (SCC / BCC / melanoma) | Non-healing ulcer, irregular border, colour change, sun-exposed site [2] | 「粒嘢有冇爛咗好耐都唔好？有冇變色？」 | |
| Soft tissue sarcoma | Deep, > 5 cm, firm, rapid growth, fixed to deep structures | Palpation: deep to fascia, immobile on muscle contraction | |
| Pitfalls | Abscess (early, without fluctuance) | Warm, tender, erythematous, evolving | 「摸落去有冇覺得暖暖哋同痛？」 |
| Hernia (inguinal/femoral) | Reducible, cough impulse, in groin/scrotal region | 「你咳一吓」(cough impulse); 「瞓低之後有冇縮返入去？」 | |
| Ganglion cyst | Firm, over joint/tendon, transilluminates | Transillumination positive | |
| Masquerades | Thyroid nodule (if anterior neck) | Moves with swallowing, thyroid status symptoms [3] | 「吞口水嗰陣粒嘢有冇郁？有冇心跳快、手震、出汗？」 |
| Dermoid cyst / thyroglossal cyst (paediatric / midline neck) | Midline, moves with tongue protrusion (thyroglossal) | 「伸條脷出嚟」(ask to protrude tongue) | |
| Trying to Tell Me Something? | Cancer anxiety / health anxiety | Disproportionate worry, FHx cancer, recent bereavement | 「你最擔心嘅係咩？有冇屋企人試過有類似情況？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我同你傾吓。請問我可以點稱呼你呀？」「今日你嚟呢度有咩嘢想睇呀？」 | Scores interpersonal marks: greeting, uses patient's name, open question |
| 0:30–1:30 | HPI – characterise the lump (site, onset, duration, size change, pain, skin change, discharge) | 「嗰粒嘢喺邊度呀？」「幾時開始發現㗎？」「有冇越嚟越大？」「痛唔痛呀？」「上面皮膚有冇變色、損咗、或者流嘢出嚟？」 | Core symptom analysis; drives diagnosis |
| 1:30–2:30 | Red flags & targeted systems review (weight loss, night sweats, fever, other lumps, bleeding, appetite) | 「近排有冇瘦咗呀？」「有冇夜晚出好多汗？」「有冇發燒？」「身體其他地方有冇類似嘅嘢？」 | Must not miss malignancy / infection |
| 2:30–3:30 | PMHx, DHx, FHx, Allergy, Social Hx | 「你有冇長期病㗎？食緊咩藥？」「有冇藥物敏感？」「屋企人有冇試過生咁嘅嘢或者癌症㗎？」「你做咩工作㗎？食唔食煙飲唔飲酒？」 | Completeness of case report |
| 3:30–4:30 | ICE – uncover hidden agenda | 「你自己覺得呢粒嘢係咩嚟㗎？」(Idea)「你最擔心嘅係咩呢？」(Concern)「你今日嚟最想我幫你做到啲咩？」(Expectation) | ICE is a scored section; hidden agenda often = cancer worry |
| 4:30–5:15 | Signpost → focused physical exam discussion | 「我想了解多少少，如果需要嘅話，我可以檢查吓嗰粒嘢，你介唔介意？」 | Permission scores; links history to examination |
| 5:15–6:00 | Summarise, safety-net, close | 「等我總結吓：你喺（部位）發現咗粒嘢，已經有（時間），你最擔心係（concern）。我建議幫你安排檢查，如果粒嘢突然變大、痛、或者流血，請即刻嚟返。有冇其他嘢想問？」 | Summary + safety-net + checking understanding = high marks |
Hidden agenda tip: For a localised lump, the patient often comes because they fear cancer (癌症). Ask 「你最擔心嘅係咩？」 early to unlock this – it is frequently the ONE main reason for consultation. [1]
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the lump? | 「粒嘢喺邊度呀？」 | Anatomical site narrows DDx hugely (neck vs breast vs groin vs skin) | Neck → thyroid/LN; Breast → fibroadenoma/CA; Groin → hernia/LN |
| Onset & Duration | When did you first notice it? | 「幾時開始發現㗎？」 | Acute = abscess/cyst; chronic/slow = benign; rapid growth = malignancy | Weeks-months progressive → malignancy red flag [2] |
| Size change | Has it grown bigger? | 「有冇越嚟越大呀？」 | Progressive enlargement = red flag | Rapid ↑ → malignancy, haemorrhage into cyst |
| Pain | Is it painful? | 「痛唔痛呀？」 | Pain → infection/inflammation; painless lump → malignancy | Painful: abscess, inflamed cyst; Painless: lipoma, malignancy [1] |
| Skin changes | Any redness, ulcer, or discharge? | 「上面有冇紅、爛咗、或者流膿？」 | Skin involvement → epidermal origin, malignancy, or infection [1] | Punctum → sebaceous cyst; ulcer → SCC/BCC; peau d'orange → CA breast |
| Number | Any other lumps elsewhere? | 「身體其他地方有冇其他粒嘢？」 | Multiple = lipomatosis, generalised lymphadenopathy, NF | Multiple → systemic disease |
| Red flags: B-symptoms | Weight loss, night sweats, fever? | 「有冇瘦咗、夜晚出汗、發燒？」 | Constitutional symptoms → lymphoma, metastatic CA, TB | Lymphoma, metastatic malignancy |
| Trauma / cause | Any injury or insect bite? | 「有冇撞親或者俾蟲咬？」 | Traumatic origin → haematoma, foreign body granuloma | Haematoma, reactive swelling |
| Function | Does it affect your daily life? | 「有冇影響你日常生活？」 | Functional impact = biopsychosocial domain | Cosmetic distress, restricted movement |
| PMHx | Any chronic illness or previous cancer? | 「有冇長期病或者以前有冇生過癌症？」 | Previous malignancy → metastasis; DM → abscess risk | Metastatic node, diabetic abscess |
| DHx | Any medication? Anticoagulants? | 「食緊咩藥？有冇食薄血丸？」 | Anticoagulants → haematoma | Warfarin-related haematoma |
| Allergy | Any drug allergy? | 「有冇藥物敏感？」 | Safety; Case Report requirement | — |
| FHx | Any family history of lumps or cancer? | 「屋企人有冇試過生粒嘢或者有癌症？」 | FHx breast CA, thyroid CA, NF, MEN | Hereditary cancer syndromes |
| Social | Smoking? Alcohol? Occupation? Sun exposure? | 「食唔食煙？飲唔飲酒？做咩工作？有冇成日曬太陽？」 | Sun → skin CA; occupation → exposure | Outdoor work + sun → SCC/BCC/melanoma [2] |
| Sexual / menstrual (if breast) | Last menstrual period? Cyclical change? | 「你最後一次嚟M幾時？粒嘢有冇跟住月經變大縮細？」 | Cyclical breast lump → fibroadenosis; pregnancy → physiological | Fibrocystic change, lactational abscess |
| ICE | What do you think it is? What worries you? What do you want me to do? | 「你自己覺得係咩？最擔心咩？想我點幫你？」 | Scored directly in Case Report | Cancer fear = common hidden agenda |
Case Report Form Answer Builder
- Format: "Localised lump at [site] for [duration]"
- Capture: site, onset, duration, size change, pain, skin changes, discharge, associated symptoms (red flags), functional impact
- Example: "A painless, gradually enlarging lump on the right side of the neck for 3 months, with no skin changes, no B-symptoms"
- Most likely: "Patient noticed the lump is getting bigger and is worried it might be cancer"
- Alternatives: cosmetic concern; pain/discomfort interfering with daily life; advised by family member to seek medical attention
- Phrase it from the patient's perspective, not the disease perspective
| Component | Likely Example | Exact Wording for CRF |
|---|---|---|
| Idea | Patient thinks it might be a tumour/cancer | "Patient thinks the lump may be cancerous" |
| Concern | Fear of malignancy; fear of surgery | "Patient is worried it could be cancer and is afraid of needing an operation" |
| Expectation | Wants reassurance, investigation, or removal | "Patient hopes to have the lump checked and removed if necessary" |
Choose based on presentation cues:
- Subcutaneous, soft, mobile, no skin attachment → Lipoma
- Central punctum, attached to skin, expressible → Sebaceous (epidermoid) cyst [1]
- Young woman, smooth round mobile breast lump → Fibroadenoma
- Neck lump moving with swallowing → Thyroid nodule [3]
- Tender, red, warm → Abscess
- Support with minimum evidence: site + consistency + mobility + skin attachment + duration
| DDx | Key Discriminator |
|---|---|
| Lipoma | Soft, lobulated, subcutaneous, freely mobile, no punctum |
| Sebaceous cyst | Punctum, attached to skin, may express cheesy material |
| Lymphadenopathy (reactive vs malignant) | Location in LN drainage area, tenderness (reactive) vs hard/fixed (malignant) |
(Adjust based on site: if breast → fibroadenoma, breast cyst, CA breast; if neck → thyroid nodule, LN, branchial cyst; if groin → hernia, LN, saphena varix)
| Domain | Problem |
|---|---|
| Biological | Risk of malignancy requiring investigation (e.g. triple assessment for breast, FNAC/biopsy for suspicious lump) |
| Psychological | Anxiety about cancer / fear of surgery |
| Social | Impact on work/daily activities; cosmetic concern affecting self-image; financial worry about medical costs |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Sebaceous (epidermoid) cyst | Central punctum visible on inspection [1] | Inspect overlying skin carefully; look for a small dark dot on the summit | Pathognomonic: punctum = blocked sebaceous duct opening; no other lump has this sign |
| Lipoma | Soft, lobulated, freely mobile mass with normal overlying skin; can pinch skin above it [1] | Pinch skin over lump → skin moves freely (not attached); palpate → soft, slippery edges | Confirms subcutaneous, non-epidermal origin; distinguishes from cyst (attached to skin) |
| Breast cancer | Skin dimpling or peau d'orange [2] | Ask patient to raise arms → look for skin tethering / dimpling; inspect for orange-peel skin | Indicates tethering of Cooper's ligaments by tumour; highly specific for malignancy |
| Malignant lymph node | Hard, non-tender, fixed node > 2 cm | Palpate – assess consistency, mobility, tenderness | Hard + fixed + non-tender = red flag for malignancy vs soft/tender = reactive |
| Abscess | Fluctuance + warmth + erythema | Press centre with one finger, feel periphery with another; compare temperature to surrounding skin | Fluctuance = pus collection; warmth/erythema = active infection |
| Thyroid nodule | Lump moves with swallowing [3] | Ask patient to swallow a sip of water; observe lump movement | Thyroid is attached to pretracheal fascia → moves with swallowing; other neck lumps do not |
| Inguinal hernia | Cough impulse | Place fingers over lump and ask patient to cough | Expansile cough impulse = communication with peritoneal cavity |
| Ganglion cyst | Transillumination positive | Darken room, place penlight against lump; observe light transmission | Cystic fluid-filled → transilluminates; solid lumps do not |
Top Traps That Lose Marks
- Forgetting to ask about red flags (B-symptoms, rapid growth, fixity) → loses marks in HPI and misses serious DDx
- Not asking ICE → entire scored section lost; cancer worry is almost always the hidden concern
- Describing the lump without stating relationship to skin and deep structures → cannot distinguish epidermoid cyst (attached to skin) from lipoma (subcutaneous, NOT attached to skin) from deep lesions [1]
- Not asking about site-specific questions: breast lump without asking about nipple discharge/menstrual cyclicity; neck lump without asking about swallowing movement/thyroid symptoms
- Writing "to rule out malignancy" as the RFC → RFC should be patient-centred (e.g. "worried it might be cancer"), not doctor-centred
- Forgetting to examine regional lymph nodes when examining any lump → always mentioned in clinical demonstration [1]
Must-not-miss red flags → urgent referral:
- Hard, fixed, rapidly growing, painless lump
- Non-healing ulcer > 3 weeks
- B-symptoms (weight loss, night sweats, fever)
- Skin changes suggesting malignancy: irregular border, colour change, ulceration, peau d'orange [2]
- Supraclavicular lymphadenopathy (Virchow's node) → intra-abdominal malignancy
- New lump in patient with known cancer history
Shortest safe management / safety-net line:
「如果粒嘢突然變大、痛、出血、或者有其他新嘅嘢出現，請即刻返嚟睇。我會安排進一步檢查，唔使太擔心。」 (If the lump suddenly gets bigger, becomes painful, bleeds, or new symptoms appear, come back immediately. I'll arrange further investigation. Don't worry too much.)
High Yield Summary
What to ASK: Site, onset, duration, size change, pain, skin changes (punctum, ulcer, colour), attachment, mobility, B-symptoms, ICE – especially cancer fear as hidden agenda.
What to WRITE on CRF:
- Chief complaint: "Localised [site] lump for [duration]"
- RFC: Patient-centred – usually "worried about cancer"
- ICE: Idea = cancer; Concern = fear of malignancy/surgery; Expectation = investigation/reassurance/removal
- Most likely Dx: Based on site + consistency + skin attachment + mobility
- DDx: 3 alternatives with discriminators
- Biopsychosocial: biological (investigation need), psychological (cancer anxiety), social (work/cosmetic impact)
- Physical sign: Punctum (sebaceous cyst), soft/mobile/skin-free (lipoma), skin tethering (CA breast), moves with swallowing (thyroid), fluctuance (abscess)
What NOT to MISS: Hard/fixed/painless/rapidly growing → malignancy until proven otherwise. Always examine regional lymph nodes [1]. Triple assessment for any breast lump [2].
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Clinical Demonstration_Skin.pdf (Introduction, History, Physical Examination sections) [2] Lecture slides: GC 201. Skin ulcers skin and subcutaneous lesions; skin cancer.pdf; GC 181. Breast mass breast cancer; benign breast diseases; mammography; breast cancer screening.pdf [3] Senior notes: Ryan Ho Endocrine.pdf (p18 – D/dx of anterior neck lump, thyroid nodule examination)
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