Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
Your next patient is 63-year-old Gregory Hansel, a retired school caretaker presenting with a neck lump. Please take a history and perform a relevant examination.
Patient History:
Gregory Hansel - a 63-year-old male - retired school caretaker.
It's been preying on your mind for some time, but you've got a few lumps around your left neck. They're not sore or anything, but you were worried cos there were around two or three of them. You had a sore throat about 5 weeks ago and a fever, but that seemed to settle down. You only really noticed them two weeks ago, and they've been there every day when you check in the morning whilst shaving. They don't seem to be growing, but you were hoping any infection would have settled by now.
You haven’t had any trouble breathing, speaking or swallowing. You haven’t had any rashes or CNS symptoms.
Only volunteer the following information if asked directly:
Now that you mention it, you've had on and off episodes of shivers and feeling feverish for about three weeks. You've woken up three times with your bed sheets drenched in sweat. You haven't been feeling yourself either, feeling generally tired. You don't think you've lost any weight, but you don't weigh yourself regularly anyway.
Ideas, Concerns, Expectations:
You returned from a holiday to South Africa 3 months ago, so you’re worried this is some tropical infection like malaria. You hope to find out what is going on.
Past Medical History:
Multiple sclerosis. Shingles three years ago.
Drug History:
None.
NKDA.
Family History:
None.
Social History:
You live in a flat with your wife where you manage well. You're fit and active and enjoy hitchhiking. You've never smoked, but you enjoy the occasional drink on the weekend. You don't experience pain in alcohol consumption. You worked as a caretaker at the local secondary school for most of your working life.
Examination Findings:
Three firm mobile 2cm lumps in the anterior triangle and supraclavicular region.
Non-tender, non-pulsatile
You note some splenomegaly (only mention if this was checked).
Differentials:
Lymphoma
Infectious mononucleosis
Generally for lymphadenopathy, think inflammation, infection, and infiltration.
Investigations:
Bedside:
Vital signs
Bloods:
FBC = (pancytopenia indicates bone marrow infiltration)
Blood film
U&Es
LFT
CRP/ESR
LDH
Bone profile
HIV test
EBV Monospot
Imaging & Special Tests:
Excisional lymph node biopsy
If B symptoms present or signs of bone marrow infiltration = bone marrow aspirate
CXR may show mediastinal widening
Staging investigations e.g. CT or PET-CT
Management (Lymphoma):