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Lymphoma case presentation : Neck mass. History taking proforma.

Lymphoma presenting as neck node. History and clinical examination proforma.

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Lymphoma case presentation : Neck mass. History taking proforma.

  2. 2. Presenting Complaints I am presenting a case of 18 year old unmarried Hindu female student residing at Ujjain, Madhya Pradesh presenting with chief complaints of •Swelling over Left side of neck since 6 months • On and off fever since 4 months She was apparently alright before 6 months when she noticed a small pea sized swelling in left side of her neck swelling which gradually increased in size to present size of a large lemon.Swelling is painless in nature and not associated with redness,ulceration or discharge.She had episodes of on and off fever since 4 months which was associated with chills and evening rise in temperature for which she consulted physician at her place.He prescribed her some medications but details unavailable.Fever subsided after medications temporarily but then again she had similar episodes of fever. She gives h/o weight loss(could not quantify).
  3. 3. Negative history No history of ● Pain in ear or ear discharge ● Nasal discharge ● Oral ulcer/toothache/tooth extraction/scalp infection ● Difficulty in swallowing ● Change of voice/cough/breathlessness/chest pain/hemoptysis ● Trauma to upper limb/swelling in armpit/boil ● Abdominal pain/bleeding gums ● Excessive sweating/itching/Excessive feeling of fatigue ● Burning micturition/haematuria/pervaginal bleeding ● Chronic medication in past
  4. 4. Personal history ● Diet: Vegetarian ● Appetite:Adequate ● Sleep:Adequate ● Bowel/Bladder:Unaltered ● Addiction:Nil ● Drug allergy:Nil
  5. 5. Past history ● No h/o similar illness in past. ● No h/o Tuberculosis in past or contact Tuberculosis. ● No h/o previous blood transfusions or any surgical procedure. ● No h/o Diabetes or heart ailment or asthma in past. ● No h/o any prior radiation.
  6. 6. Family history ● Both the parents are alive and she has a younger sibling(brother). ● There is no history of major illness in family (any cancer/heart ailment)
  7. 7. Menstrual history ● Age of menarche: 13 years. ● Menstrual cycles occur at regular periodic intervals with moderate pain with moderate bleeding(2 pads/day for 4-5 days).
  8. 8. General Examination Patient has been explained about examination procedure in detail and verbal consent taken.Patient examined in adequate light and proper exposure with adequate privacy. Patient is conscious/cooperative and well oriented to time/place/person.She is average built and nourished.No pallor/icterus/cyanosis/clubbing edema. Height:42 kg Weight:156 centimetre ● Pulse :88 bpm in right radial artery in sitting position; regular and good force,volume and tension in sitting position. ● BP:120/80 mm Hg in right brachial artery in supine position.Noradioradal radiofemoral delay ● RR:18 cycles/min;regular and thoracoabdominal
  9. 9. Local examination A.Inspection Right side of neck:No abnormality seen. Left side:An approximately 4*3 cm spherical swelling appears in left anterior upper neck.Skin over swelling appears normal.No evidence of redness/ulceration/discharge or dilated veins over swelling.It doesn’t move with swallowing or protrusion of tongue.No restriction of neck movement. B Palpation Inspectory findings are confirmed by palpation.Temperature over swelling is normal single 4*4*3 cm lymph node palpable on left side of neck from Level II to Level III which is firm, rubbery,discrete,non tender and mobile.Skin over swelling free.No fixity to muscle
  10. 10. No any other lymph nodes palpable on left side of neck including level IV/level V/preauricular/postauricular/occipital.Similarly no lymph nodes palpable on the right side of neck.No b/l axillary/epitrochlear/paraaortic/inguinal/popliteal lymph nodes palpable. No visible and palpable abnormality detected in oral cavity, oropharynx and nasal cavity .
  11. 11. Systemic examination P/A: Inspection- Abdomen is flat.Umbilicus is central and inverted.No dilated veins or any scar seen. Palpation-No tenderness/guarding/rigidity present.No organomegaly present.No free fluid. Auscultation-Bowel sounds present. RS: Air entry bilaterally equal.No added sounds CNS:Higher mental functions normal. CVS:S1S2 normal.No abnormal sounds heard.

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    Jul. 26, 2021

Lymphoma presenting as neck node. History and clinical examination proforma.


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