Your task is to characterise the lump (confirming it is a lymph node) and, most importantly, to perform a systematic search for the source of the pathology (infection or malignancy) in the relevant drainage areas.
Entry & Preparation
Enter the room, wash your hands visibly, and approach the patient.
- Candidate: “Good morning. My name is Dr. [Name]. I am one of the exam doctors. I have been asked to examine your groin area today. Is that okay?”
- Patient: “Yes.”
- Candidate: “This will involve me feeling the lump in your groin and then examining your legs and tummy to look for any causes. It involves examining sensitive areas, but I will maintain your dignity at all times. Would you like a chaperone?” (Always offer for intimate exams).
Positioning & Exposure
Action: The patient should be lying supine (flat). Expose the abdomen from the umbilicus down to the mid-thighs initially, but warn that you will need to look at the legs later.
Inspection
Stand at the end of the bed or to the right side.
Verbalization: “On inspection, I am looking for any visible lumps, scars, sinuses, or skin changes in the inguinal region.”
- Lump: Is there a visible mass?
- Skin: Is there erythema (overlying infection) or a punctum/sinus?
- Scars: Previous biopsy, hernia repair, or surgery.
Action: Warm your hands. Ask about pain before touching.
Define the Lump (The “SSSS CCT” Approach)
Palpate the main mass using the pads of your fingers.
Candidate: “I am palpating the lump to characterise it.”
- Site: “It is located below and medial to the pubic tubercle (Femoral hernia usually)” OR “It is along the inguinal ligament (Lymph node).”
- Size: Estimate in cm (e.g., 2×2 cm).
- Surface & Shape: Smooth vs. irregular/matted (malignancy).
- Consistency:
- Hard: Suggests Carcinoma/Metastasis.
- Rubbery: Suggests Lymphoma.
- Fluctuant: Suggests Abscess.
- Fixation: “I am checking if it is tethered to the underlying structures or skin.”
- Tenderness: Tender usually implies inflammation/infection. Non-tender implies malignancy.
Palpate the Groups (The “T”)
Action: Even if you found one lump, palpate the rest of the chain.
- Horizontal Chain: Roll fingers parallel to the inguinal ligament.
- Vertical Chain: Roll fingers along the saphenous vein (upper medial thigh).
- Contralateral Side: “I am now palpating the other groin for comparison.” (Generalized vs. Localized lymphadenopathy).
This is where many candidates fail. You have confirmed a lymph node; now you must find why it is enlarged. You must examine the “catchment area.”
1. The Lower Limbs (Vertical Group Drainage)
Action: Expose the legs fully.
Candidate: “I am examining the legs for any source of infection or malignancy.”
- Skin: Look for Cellulitis, tracking lymphangitis (red lines), or Kaposi’s sarcoma.
- Ulcers: Venous or arterial ulcers acting as an entry point for infection.
- Between the Toes: “I am specifically checking the web spaces of the toes.” (Common site for fungal infections/Athletes foot causing secondary bacterial infection).
- Heels/Soles: Look for Acral Melanoma (a black, irregular mole on the sole of the foot).
2. The Abdominal Wall & Buttocks (Horizontal Group Drainage)
Action: Inspect the lower abdomen (below umbilicus) and ask the patient to roll over briefly to check the gluteal region.
Candidate: “I am checking the lower abdominal wall and back for skin lesions, rashes, or infected sebaceous cysts.”
3. The Genitalia & Perineum (Horizontal Group Drainage)
Note: In an AMC exam, this is often a sensitive area. You usually verbalise this unless a mannequin is provided.
Verbalisation Essential
Candidate (to Examiner): “To complete my examination of the drainage areas, I would like to inspect the external genitalia.”
- Male: Penile ulcers (Syphilis, Herpes), Penile cancer (SCC), Scrotal masses.
- Female: Vulval lesions, vaginal discharge.
- Both: Urethral discharge (STIs).
General Lymphadenopathy Check
Action: Briefly palpate other accessible node groups if malignancy/lymphoma is suspected.
- Candidate: “I am quickly checking the axillary and cervical lymph nodes to see if this is generalized lymphadenopathy (e.g., Lymphoma, HIV).”
- Spleen/Liver: “I would also palpate the abdomen for hepatosplenomegaly.”
Conclusion
Action: Cover the patient. “Thank you, you may dress now.” Wash your hands.
Sample Presentation
“On examination, there is a hard, irregular, non-tender lump in the right inguinal region measuring 3x3cm. It is fixed to deep structures but not the skin. It is located in the horizontal chain. Examination of the drainage areas revealed a suspicious pigmented lesion on the right heel consistent with a melanoma. There is no generalized lymphadenopathy. This clinical picture is highly suggestive of metastatic melanoma in the inguinal node.”
Google