Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is called Sam Smith – a 46-year-old gentleman presenting with a neck lump. Please take a history and perform an appropriate examination.
Patient History:
Your name is Sam Smith – 46-year-old – currently unemployed.
You noticed in the past month, that there's a growing mass in the neck. It is not painful. It is in the front of the neck on the left side around the middle of the neck. It started small and very unnoticeable one month ago, but it has now grown to the size of a small cherry tomato.
You did notice you lost quite a bit of weight in the past few months– but you are not sure how much you have lost – you only noticed your current trousers don't fit anymore. However, your appetite is poor, so you do not know whether this is related. Despite ensuring you get enough sleep, you still feel tired all the time. Otherwise, bowel habits are normal (no constipation/ no diarrhoea/ no bloody stools. No vomiting. You notice your voice has gotten a little more breathy or raspy than usual. You are also feeling slightly more breathless than usual.
You are not sure if you have any night sweats, but you generally sweat a lot all the time, including at night-time. No recent infection. No fever / rigors / unwell. No skin rashes/ bruising/ changes /itchiness. No sore throat. No tiredness. No recent infection. No skin rashes/ changes. No bruising or any abnormal bruising. No swallowing difficulty. No breathing difficulties. No pain when swallowing. No coughing of blood. No itchy skin. No hearing loss/pain.
Ideas, Concerns, Expectations:
You have no idea what might be causing this lump, but you know your father previously had a lump associated with his thyroid, so you think it is related. You are concerned because the lump is getting bigger. You hope to find out what is going on.
Family History:
Grave’s Disease
Past Medical History:
History of alcoholism, hypertension, diabetes type 2, hypercholesteremia, GORD
Drug History:
Metformin, Ramipril, Statin, Omeprazole
NKDA
Social History:
Smoker
You tried to quit alcohol without success – you are currently averaging around 3-4 cans of lager per day without any difficulties (not associated with pain when drinking alcohol).
You used to work as an accountant but were made redundant recently.
You have been having quite a few sessions of binge drinking lately.
Examination Findings:
Neck lump diameter 3-4 cm located in the left anterior midway region of the neck. The lump is hard + rubbery, and oval-shaped. Non-mobile. Tethered/fixed to underlying skin and tissue. No Erythema/ ulceration. Not warm to touch. No tenderness on lump palpitation. No tethering of underlying tissue. Not pulsatile. Doesn't move with swallowing or tongue movement. Does not transilluminate with light. Chest clear – no focal chest sound. No clubbing. No hepatosplenomegaly. No abnormal bleeding. No goitre can be palpated. No cranial nerve palsy. No features of Horner's syndrome. Oral cavity normal (no ulceration/ lumps/ skin changes).
Differentials:
To rule out tumours (benign vs malignant)
Goitre (swollen thyroid gland) or thyroid nodules
Skin abscess / sebaceous cyst / branchial cysts/ thyroglossal cysts
Lymphadenopathy /lymphoma
Lipoma
Carotid body tumour
Sarcoidosis (non-caseating granuloma)
Investigations:
Bedside:
Observations
Bloods:
FBC / Blood Film (leukaemia + infection + anaemia + baseline)
HIV test
Monospot test / EBV antibodies IgM / IgG (infectious mononucleosis)
TFT (goitre/ thyroid nodules)
Antinuclear antibodies (SLE)
LDH ( non-specific marker for hodgkin’s lymphoma)
LFTs if suspicion of abdominal metastases
U&E ( baseline)/ albumin
Total protein (baseline / assess nutritional status)/ Bone profile (may indicate bony metastases)
ACE Levels ( sarcoidosis)
Imaging:
Modified barium swallow if indicated for assessment for dysphagia + aspiration
Urgent USS Neck to look for soft tissue sarcoma
CT Scan – staging / cancer / metastasis
Nuclear scan – e.g. toxic thyroid nodules / PET scan for metastatic cancer
Consider MRI if appropriate
Consider CXR – lung tumour/ infection/ sarcoidosis (hilar adenopathy)
Special Test:
Consider pharyngolaryscopy if appropriate
Consider fibre-optic/rigid direct laryngoscopy (to look for irregular mass in the larynx) +/- biopsy
Consider rigid videostroboscopy (vocal cord fixation)
Consider fluorescence endoscopy (loss of autofluorescence in dysplastic lesion)
Biopsy e.g. fine needle aspiration cytology, core biopsy, incision biopsy
Consider in situ hybridisation for HPV-16, p16 immunohistochemistry or PCR in biopsy specimen
Management (Head & Neck Cancer):