IM13.7-10 | Cancer Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

Oncological history: document presenting complaint (lump, bleeding, organ dysfunction, constitutional symptoms); quantify tobacco in pack-years; elicit occupational carcinogens, reproductive history (in women), and structured family pedigree; assess ECOG performance status (0 = fully active, 4 = completely disabled; PS ≥2 affects chemotherapy eligibility).

General examination: weight/BMI/cachexia, pallor, jaundice (hepatic metastasis), lymphadenopathy (all chains — Virchow's left supraclavicular = upper GI primary), clubbing, paraneoplastic skin signs (acanthosis nigricans, dermatomyositis). Abdominal: hepatomegaly texture (smooth vs. nodular), ascites (shifting dullness), Sister Mary Joseph nodule.

Breast examination: three inspection positions; flat-finger palpation covering all quadrants + tail of Spence; characterise lump in 6 descriptors; axillary node assessment in 4 groups. Triple assessment: clinical E + imaging I + histopathology H — concordance required for benign diagnosis.

DRE: Sims' position; 360° rotation; prostate assessment (hard/irregular/no median sulcus = malignancy); glove inspection for blood/mucus. Check PSA BEFORE DRE.

Pap smear: speculum in vaginal axis; Cervex-Brush 5 clockwise rotations into endocervical canal; immediate fixation within 20–30 seconds; bimanual assessment for cervical mobility (fixed cervix = parametrial invasion).

Differential diagnosis: integrate presenting syndrome + epidemiological priors + examination pattern → rank by probability → triple assessment or tissue biopsy to confirm leading diagnosis.

REFLECT

Think about the patient in the opening hook — Meena, with her changed bowel habit and anaemia. After taking a full oncological history and performing a systematic examination including DRE, you have now found a palpable rectal mass and pallor consistent with chronic blood loss. How do you communicate the examination finding to her before investigations are complete? At what point in the consultation do you begin to prepare a patient for the possibility of a cancer diagnosis — and how do you balance thoroughness with the risk of causing unnecessary anxiety before histological confirmation? Reflect also on the procedural skills in this module: breast examination and DRE are intimate examinations with significant potential for patient discomfort and embarrassment. What communication strategies and examination habits will you build into every performance of these skills to maintain dignity and trust?