Palpation guided fine needle aspiration
Patient history and exam

Topic Completed: 1 August 2013

Revised: 3 January 2019, last major update August 2013

Copyright: (c) 2002-2018,, Inc.

PubMed Search: Patient history and exam fine needle aspiration

Joseph D. Jakowski, M.D.
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Cite this page: Jakowski J. D. Patient history and exam. website. Accessed May 24th, 2020.
Focused patient history and physical exam for the FNA patient
Evaluating the patient history of symptoms:
  • Taking a patient history of symptoms is facilitated with mnemonic "OPQRST":
  • Onset
    • Who first noticed the condition?
    • What was the patient doing / what was going on when the symptoms became apparent (e.g. trauma to the area, concurrent infections?)
    • Was the onset sudden, gradual or appears to be chronic
  • Provocation or palliation
    • Whether any movement, palpation, medications or other external factor makes symptoms better or worse
  • Quality
    • This is the patient's description of associated symptoms, for example pain with additional qualifiers of sharp, dull, crushing, burning, tearing; also the pattern of pain such as intermittent, constant, throbbing
  • Region and radiation
    • Example: "Is this the only enlarged lymph node you have noticed or are there more in a different area?"
    • If there is pain in a lump, you can ask if it extends or moves to any other area
  • Severity
    • If there is pain you can assess with a pain score (usually on a scale of 0 to 10) or ask as a comparative such as "... compared to the worst pain you have ever experienced"
  • Time (history)
    • Example: "How long has the lump been there and how it has changed since onset?"
    • "Has this swelling ever happened before?"

Physical examination of the patient's lump:
  • Below are key characteristics to assess during physical examination of a patient's lump and also for documentation purposes if needed for billing of Evaluation and Management (E/M) CPT codes:
    • Site, Size, Shape, Surface, Skin, Scar
    • Tenderness, Temperature, Transillumination
    • Consistency
    • Attachment
    • Mobility
    • Pulsation
    • Fluctuation
    • Irreducibility
    • Regional lymph nodes
    • Edges
Physical exam signs and findings to assess the differential diagnoses in the FNA patient
  • A helpful mnemonic to remember the broad categories of differential diagnoses in a patient is given by the mnemonic "MINT CANDY":
    • Metabolic
    • Infection
    • Neoplastic
    • Trauma
    • Collagen vascular disease
    • Allergic
    • 'N'ything else
    • Drugs
    • Youth - congenital disease

Common painful skin tumors: Can be remembered by using the pneumonic "LEND AN EGG": (J Am Acad Dermatol 1993;28:298)
  • Leiomyoma
  • Eccrine spiradenoma
  • Neuroma
  • Dermatofibroma
  • Angiolipoma
  • Neurilemmoma
  • Endometrioma
  • Glomus tumor
  • Granular cell tumor

Sister Mary Joseph sign or node: palpable nodule of the umbilicus as a result of metastasis of a pelvic or abdominal cancer (most commonly gastric, colonic or pancreatic cancer or gynecologic tract cancer in women)

Virchow's node: lymph node in the left supraclavicular fossa that is enlarged, firm and strongly indicative of metastatic cancer from the abdomen (especially gastric cancer); differential also includes lymphoma, other intra abdominal malignancies, breast cancer and infection (e.g. of the left arm)

Dimple sign or Fitzpatrick's sign: dimpling of the skin with lateral compression, considered by many to be pathognomonic for dermatofibroma

Transillumination test:
  • Simple technique for examination of superficial lumps which involves a bright light that is projected at or through an area of interest, for example, in the head and neck or breast
  • To perform, the exam room lights are dimmed or turned off and a bright light is then pointed at a location on the body to be examined
  • Solid masses will tend to be black, cysts will tend to light up or illuminate

Positive Tinel's sign: paresthesias / pain / tingling elicited by mechanical stimulation over the distribution of the nerve suggest peripheral nerve tumors (schwannona, neurofibroma)
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