How should I document a physical exam on a patient presenting with a raised neck tendon on the left side who has a history of testicular cancer?

Documentation of Physical Exam for Raised Neck Tendon in Patient with Testicular Cancer History

Given this patient's history of testicular cancer, you must document this as a "left supraclavicular lymph node" rather than a "raised neck tendon," as left supraclavicular nodes represent a known metastatic pathway for testicular cancer and require urgent oncologic evaluation. 1

Critical Documentation Elements

Anatomical Description

• Document the precise location: Specify "left supraclavicular region" or "left supraclavicular fossa" rather than vague terms like "neck tendon" 1, 2
• Measure and record the size: Document the greatest diameter in centimeters (masses >1.5 cm are high-risk for malignancy) 1, 2
• Describe the consistency: Document whether the mass is firm, hard, or soft (firm consistency suggests malignancy) 1, 2

High-Risk Physical Examination Features to Document

• Fixation to adjacent tissues: Note whether the mass is mobile or fixed to underlying structures 1, 2
• Skin changes: Document any ulceration of overlying skin 1, 2
• Tenderness: Note whether the mass is tender or nontender (nontender masses are more concerning for malignancy) 2
• Laterality: Confirm this is on the left side, as left supraclavicular nodes are the expected metastatic pathway via the thoracic duct in testicular cancer 1, 3

Why This Matters in Testicular Cancer

Testicular cancer metastasizes in a predictable pattern: retroperitoneal lymph nodes first, then via the thoracic duct to left supraclavicular nodes, and subsequently to the lungs 1. Left supraclavicular lymphadenopathy constitutes distant metastasis (M1 disease) in testicular cancer staging 1. This finding would change the patient from potentially localized disease to stage III disease, dramatically altering management 4, 5.

Required Additional Physical Examination Components

Targeted Examination for Malignancy Risk

• Visualize the oropharynx, base of tongue, and larynx: While testicular cancer doesn't originate here, you must rule out a second primary malignancy given the neck mass 1, 2
• Examine the scalp, face, and oral cavity: Document findings to exclude other head and neck primaries 2
• Palpate the entire neck bilaterally: Document presence or absence of other cervical lymphadenopathy 1, 2
• Examine the contralateral supraclavicular region: Document whether right-sided nodes are present 2

Testicular-Specific Examination

• Palpate both testicles: Document any masses, asymmetry, or abnormalities (even if the patient had prior orchiectomy, document the surgical site) 1, 5
• Examine the abdomen: Palpate for masses or hepatomegaly that might suggest retroperitoneal or hepatic metastases 1

Documentation Template Structure

Document in this algorithmic format:

Left supraclavicular mass:

• Size: [X] cm in greatest diameter 1, 2
• Consistency: firm/hard/soft 1, 2
• Mobility: mobile vs. fixed to underlying structures 1, 2
• Tenderness: tender vs. nontender 2
• Overlying skin: intact vs. ulcerated 1, 2
• Duration: present for [X] weeks/months 1, 2

Associated findings:

• Other cervical/supraclavicular lymphadenopathy: present/absent 2
• Oropharyngeal examination: normal/abnormal 1, 2
• Testicular examination: [findings] 1, 5
• Abdominal examination: [findings] 1

Immediate Next Steps to Document

Document your assessment and plan explicitly:

• State "patient at increased risk for malignancy given history of testicular cancer and physical examination findings" 1, 2
• Document that you explained the significance of these findings to the patient 1, 2
• Order CT neck with contrast (or MRI with contrast if CT contraindicated) to characterize the mass 1, 2, 6
• Order CT chest, abdomen, and pelvis with contrast for staging, as this may represent metastatic testicular cancer 1, 7
• Check serum tumor markers: AFP, β-HCG, and LDH 1, 4, 5
• Document urgent referral to oncology (or urology if patient is not already under oncologic care) 2, 4

Critical Pitfalls to Avoid

• Do not dismiss this as a benign "tendon" or "muscle strain": In a patient with testicular cancer history, any left supraclavicular mass must be considered metastatic disease until proven otherwise 1, 4
• Do not prescribe empiric antibiotics: Antibiotics should not be given unless there are clear signs of bacterial infection (fever, erythema, fluctuance), as this delays appropriate oncologic evaluation 1, 2
• Do not order imaging without contrast: Contrast is essential for characterizing the mass and identifying potential metastatic disease 2, 6
• Do not perform open biopsy before imaging: Complete imaging and consider FNA first if diagnosis remains uncertain after imaging 1, 2