1
Identification
- Name, age, sex, occupation
2
Presenting Complaint
- Lump / pain / bleeding / obstruction
3
HPI
- SOCRATES for pain
- Lump: duration, size change, pain, discharge
- B-symptoms if oncological
4
Past Surgical / Anaesthetic History
- Procedures, complications, ICU stay
5
Drug & Allergy History
- Anticoagulants, steroids, latex allergy
6
Social History
- Smoking pack-years, alcohol, BMI, exercise tolerance
7
Examination
- General — pallor, jaundice, clubbing, LN
- Local: inspect, palpate, percuss, auscultate
- Systemic exam
8
Summary
- Problem list
- Anatomical + pathological diagnosis
9
Investigations
- Bloods, imaging (USS, CT, MRI)
- Tissue diagnosis
10
Management
- Conservative, medical, surgical
- Pre-op optimisation, consent, post-op care
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