Background Lung nodule management remains a challenge to clinicians, especially in endemic tuberculosis areas. Different guidelines are available with various recommendations; however, the suitability of these guidelines for the Asian population is still unclear. Our study described the prevalence of malignant lung nodules among nodules measuring 2–30 mm, the demographic and characteristics of lung nodules between benign and malignant groups, and the clinician's clinical practice in managing lung nodules. Method Retrospective review of lung nodules from the computed tomography archiving and communication system (PACS) database and clinical data from January 2019 to January 2022. The data was analysed by using chi square, mann whitney test and simple logistic regression. Results There were 288 nodules measuring 2–30 mm identified; 49 nodules underwent biopsy. Twenty-seven (55%) biopsied nodules were malignant, (prevalence of 9.4%). Among the malignant lung nodules, 74% were adenocarcinoma (n = 20). The commonest benign nodules were granuloma n = 12 (55%). In nodules > 8 mm, the median age of malignant and benign was 72 ± 12 years and 66 ± 16 years, respectively (p = 0.024). There was a significant association of benign nodules (> 8 mm) in subjects with previous or concurrent tuberculosis (p = 0.008). Benign nodules are also associated with nodule size ≤ 8 mm, without spiculation (p < 0.001) and absence of emphysema (p = 0.007). The nodule size and the presence of spiculation are factors to make the clinicians proceed with tissue biopsy. Spiculated nodules and increased nodule size had 11 and 13 times higher chances of undergoing biopsy respectively (p < 0.001).) Previous history of tuberculosis had a 0.874 reduced risk of progression to malignant lung nodules (p = 0.013). These findings implied that these three factors are important risk factors for malignant lung nodules. There was no mortality association between benign and malignant. Using Brock's probability of malignancy, nodules ≤ 8 mm had a low probability of malignancy. Conclusion The prevalence of malignant lung nodules in our centre was comparatively lower than non-Asian countries. Older age, the presence of emphysema, and spiculation are associated with malignancy. Clinical judgment is of utmost importance in managing these patients. Fleishner guideline is still being used as a reference by our clinician.