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This article provides a structured approach to the examination of a lump in an OSCE setting. The guide is generic and can be used to assess most lumps that patients present with. We do, however, also have some more specific guides for hernia examination, neck lump examination and thyroid lump examination.

You can check out the lump examination OSCE mark scheme here.

 


Introduction

  • Wash your hands
  • Introduce yourself
  • Confirm the patient’s details (e.g.name and date of birth)
  • Explain the procedure:
    • “Today I need to perform an examination of the lump you are concerned about, which will involve me having a look and feel of the lump.”
    • “It shouldn’t be painful, however, it might be a little uncomfortable. If at any point you are in pain or would like me to stop, just let me know.”

 

Explain the need for a chaperone:

  • “For this examination one of the nursing staff will be present acting as a chaperone.”

 

Check the patient’s understanding and gain consent:

  • “Do you understand everything I’ve explained?”
  • “Do you have any questions?”
  • “Are you happy for me to perform the procedure?”

 

Check if the patient has any pain before you begin:

  • “Are you currently experiencing pain anywhere?”

 

  • Expose the patient appropriately

 


General Inspection

  • Note any evidence of pain (e.g. stance/grimacing)
  • Note the patient’s overall colour (e.g. pallor secondary to anaemia or jaundice)
  • Note any evidence of abdominal distension (may suggest bowel obstruction, possibly due to an incarcerated hernia)
  • Note any muscle wasting or cachexia suggestive of underlying malignancy
  • Look around the bed for evidence of vomit bowels or medication boxes

 


Close Inspection

Site

  • Be precise (e.g. mid-point of the inguinal canal)
  • If there are multiple lumps, this is more suggestive of superficial lymph nodes, superficial lesions (e.g. lipoma) or dermatological problems (e.g. large skin lesions)

 

Size

  • Use a tape measure if available (otherwise, a shortcut is to measure and memorise the length of the distal phalanx of your index finger, and use that as a reference)

 

Shape

  • This refers to the whole outline of the lump (e.g. round/oval/irregular/well-defined)

 

Colour

  • Is the lump a different colour from the surrounding skin (e.g. erythematous)?

 

Contour

  • This refers to the look and texture of the skin overlying the lump
  • Is it same as rest of the skin, or thick/rough/scaly/smooth/shiny?

 


Palpation

Tenderness

  • Press on the lump and look at the patient’s face to see if they grimace
  • Ask the patient if the lump is painful
  • Is the whole lump tender or just a part of it?

 

Temperature

  • Palpate the temperature using the back of your hand, comparing to surrounding tissue
  • Significantly increased temperature suggests infection (e.g. abscess) and will normally be associated with erythema

 

Consistency

  • Comment whether the lump is hard, firm, soft or nodular
  • Hard corresponds to the feel of your forehead, firm to the tip of your nose, and soft to your lip

Tethering

  • Is the lump freely mobile, or is it tethered to a structure such as skin or muscle?
  • Malignant lumps are often fixed to surrounding tissue

 

Pulsatility

  • Is the lump pulsatile?
  • Pulsatility suggests underlying vascular aetiology (e.g. an aneurysm)

 

Lymphadenopathy

  • Palpate the lymph nodes that drain the area the lump is located within (commonly the inguinal lymph nodes are assessed when an inguinal hernia is suspected)
  • Lymphadenopathy surrounding the lump suggests either infective or malignant aetiology

 


Auscultation

Bruit

  • Auscultate the lump for a bruit (suggestive of vascular aetiology)
  • Listen for bowel sounds and if present, it suggests the lump contains bowel (e.g. as is often the case in a hernia)

 


Other tests

Compressibility

  • This test should only be used for suspected hernias
  • Check it the lump can be compressed (a.k.a reduced)
  • You can ask the patient to do this, or do it yourself
  • If the lump can be reduced completely, it may only reappear if the patient increases pressure (e.g. by coughing)
  • You can ask the patient to lie down and if the lump reduces spontaneously, this makes the diagnosis of a hernia highly likely
  • Hernias are typically reducible, however, if a hernia is painful and irreducible it suggests that it is strangulated (this is a surgical emergency)

Cough impulse

  • This test should be used for suspected hernias
  • Ask the patient to cough whilst you palpate the lump
  • A positive cough impulse occurs when you see and/or feel the lump increase in size when the patient coughs
  • A cough impulse indicates a communication between the intra-abdominal cavity and the lump (e.g. a hernia)

Transillumination

  • Ideally dim the lights in the room first
  • Shine a light through the lump and see if it illuminates
  • Transillumination suggests that the lump is cystic (e.g. hydrocoele)

 


To complete the examination

  • Thank the patient
  • Allow the patient time to get re-dressed
  • Document the examination in the medical notes including the details of the chaperone (if relevant)
  • Suggest a differential diagnosis for the lump (common lumps in OSCEs include hernias, lipomas, arteriovenous fistulas, neck lumps)

 

Summarise findings

Example 1

“Mr X has a single lump in his right anterior cubital fossa. It is a well-defined oval 5x3cm across and 3cm in height. The overlying skin is shinier and slightly darker than the surrounding skin. It is soft, smooth and non-compressible. It is not tender, it is the same temperature as the surrounding skin and is freely mobile. The lump is pulsatile with an audible bruit. My findings are consistent with an active brachiocephalic arteriovenous fistula.”

 

Example 2

“Mrs Y has a single lump in the posterior wall of his left axilla. It is a poorly-defined sphere around 5cm across. The colour and contour are the same as the surrounding skin. It is hard, smooth and non-compressible. It is not tender, it is the same temperature as the surrounding skin and is tethered to deeper structures. The lump is non-pulsatile with no bruit. My findings are consistent with a suspicious lymph node.”

 

Example 3

“Mr Z has a single lump in the umbilical region 5cm left of the umbilicus. It is a well-defined hemisphere with a 10cm radius. The colour and contour are the same as the surrounding skin. It is soft and reducible, reappearing with a cough impulse. It is tender, the same temperature as the surrounding skin and is freely mobile. There are audible bowel sounds and it is not pulsatile or transilluminating. My findings are consistent with a paraumbilical hernia containing loops of bowel.”

 

Suggest further assessments and investigations

 


 

Assessment

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