How do I document a mobile subcutaneous mass on the back in progress notes?

Documentation of Mobile Subcutaneous Mass on the Back

Document the mass as "mobile subcutaneous mass" with specific descriptors including size, consistency, depth relative to fascia, presence of tenderness, and skin changes, followed by systematic characterization to guide appropriate imaging and management.

Essential Documentation Components

Physical Examination Details

• Mobility: Describe the mass as "freely mobile" or "mobile in all directions," which suggests a benign lesion not fixed to underlying structures 1
• Size: Measure and document dimensions in centimeters, as masses >5 cm require different management algorithms 1, 2
• Consistency: Specify whether the mass is soft, firm, or rubbery—soft consistency suggests lipoma (the most common superficial mass at 96% frequency), while firm consistency raises concern for malignancy 1, 2
• Depth: Clearly state whether the mass is superficial (above the fascia) or deep (below the fascia), as deep location significantly increases concern for atypical lipomatous tumor or sarcoma 1, 2
• Skin changes: Note any overlying skin abnormalities, dimpling, or color changes 3
• Tenderness: Document presence or absence of pain on palpation, as tenderness may indicate infection, rapid growth, or malignancy 1, 4

Critical Red Flags to Document

• Growth rate: Specifically note if the patient reports rapid growth or recent change in size, as this mandates advanced imaging 1, 2
• Duration: Document how long the mass has been present 4
• Associated symptoms: Include any neurological symptoms, weakness, or systemic signs 1

Recommended Documentation Template

A suggested format would be: "Mobile subcutaneous mass measuring [X] cm located on the [specific anatomic location] of the back, [superficial/deep] to the fascia, [soft/firm] consistency, [tender/non-tender], with [normal/abnormal] overlying skin. The mass is freely mobile in all directions without fixation to underlying structures. [Present/absent] rapid growth reported by patient."

Differential Diagnosis Considerations in Documentation

Most Likely Diagnoses

• Lipoma: The overwhelming majority (96%) of mobile superficial masses are benign lipomas, characterized by soft consistency and free mobility 1, 2
• Epidermoid cyst: Consider when there is a central punctum or skin attachment 1
• Vascular malformation: May have bluish discoloration or compressibility 1

Concerning Features Requiring Specialist Referral

• Document any of the following that mandate referral to a sarcoma center before biopsy: size >5 cm, deep (subfascial) location, firm consistency with irregular margins, rapid growth, or pain 1, 2
• Atypical lipomatous tumor (ALT): Any lipomatous mass that is increasing in size, deep-seated, or located in the lower extremity raises concern for ALT, which requires different surgical planning 1, 2

Imaging Pathway Documentation

Initial Imaging Orders

• Radiographs first: Document that plain radiographs of the area were ordered, as this is the fundamental first step that identifies calcifications, bone involvement, or intrinsic fat in 62% of cases 3, 5
• Ultrasound for superficial lesions: For small superficial masses, ultrasound has 94.1% sensitivity and 99.7% specificity and should be the next step 3, 1, 5

Advanced Imaging Indications

• MRI with and without contrast: Document the indication if ordering MRI, which is appropriate for masses >5 cm, deep location, atypical ultrasound features, rapid growth, pain, or diagnostic uncertainty 1, 2, 5

Common Documentation Pitfalls to Avoid

• Never rely on physical examination alone: Document that imaging is planned, as physical examination correctly identifies only 85% of soft tissue tumors 3, 1, 5
• Avoid premature biopsy: Do not document plans for biopsy before appropriate imaging, as this can compromise definitive surgical treatment if the lesion proves to be a sarcoma 3
• Don't dismiss mobile masses as benign: Mobility does not exclude malignancy—document all concerning features even if the mass is mobile 1, 4
• Specify anatomic location precisely: Vague documentation like "back mass" is insufficient; specify thoracic, lumbar, or paraspinal location as this affects differential diagnosis 3