History

CC:

“I have a painful bump on my neck” x 5 days.

HPI:

This is a 17 year old female who presents to the urgent care today with a painful bump on her neck x5 days. Pt emigrated from Pakistan to NY about 1 month prior to onset. Pt says that she had fever, sore throat and ear pain 1 week ago for about 2 days. Those symptoms resolved, and then the pt developed a painful bump on the R side of her anterior neck. The pain is a dull, constant pain that is 5/10 in severity. The pain is exacerbated to a sharp pain with movement of her neck and with palpation. Pt tried to treat it with tylenol, a massage and oils which provided no relief. The pain is only located around the bump and does not radiate. 

Denies current fever, cough, sore throat, weight loss, abdominal pain, diarrhea, fatigue, nausea, vomiting, night sweats, easy bruising/bleeding and drainage from the area.  

PMHx:

• Unknown

Medications:

• Denies prescription medication and herbal supplement use.

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Unknown

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies past or current use
• Marital History: Single
• Language: Primarily Urdu, with basic English spoken and understood
• Occupational History: Student
• Travel: Came to live here from Pakistan about 1 month ago
• Home situation: Lives at home with extended family- aunt and cousins
• Sleep: Endorses adequate sleep and feeling well rested
• Exercise: Does not exercise
• Diet: Reports balanced diet with lean protein, vegetables and carbs.
• Caffeine: Denies caffeine use 

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums, epistaxis, nasal congestion and sore throat.
• Neck: Admits to localized swelling/lumps. Denies stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies dyspnea, wheezing, cyanosis, cough and hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical: G0P0000
• Musculoskeletal: Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, well nourished female in no apparent discomfort. Appears stated age of 17. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP:  118/72 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 95 beats per minute, regular rate, rhythm and amplitude 
• T:  96.8 degrees F (temporal)
• Height: 61 inches Weight: 110 lbs BMI: 20.1

Skin & Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Nails: Capillary refill < 2 seconds.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. PERRLA. EOMS intact. No conjunctival injection or discharge. No sign of FB or trauma. Visual acuity intact. Fundoscopic exam deferred. 
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Nose/Sinuses:

• Nose: Symmetrical. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Mouth/Pharynx:

• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Mildly enlarged tonsils present with no injection or exudate. Uvula midline, pink with no edema or lesions.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. 
• Lymph nodes: No erythema, warmth or drainage of cervical nodes. 1.5×1 cm enlarged, mobile, tender R anterior cervical node. Tender and mobile L submandibular lymph node, not enlarged. All other cervical lymph nodes non-tender and not enlarged. 

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with flat contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation throughout, no guarding or rebound noted. 

Musculoskeletal: 

• Neck: No erythema, warmth or crepitus noted. Full range of motion with pain.

Differential diagnosis:

• Reactive cervical lymphadenopathy (secondary to strep pharyngitis or mononucleosis)
  • Refers to the enlargement of lymph nodes in the neck due to an immune response, typically to an infection or inflammation. The term “reactive” indicates that the lymph nodes are responding to a stimulus, such as a viral or bacterial infection, but are not diseased themselves. Streptococcal pharyngitis should be considered, especially given the patient’s recent history of fever, sore throat, and ear pain. Even though those symptoms have resolved, it’s possible that the cervical lymphadenopathy developed as a result of the preceding strep infection. Mono may cause prolonged lymphadenopathy, although the patient lacks systemic symptoms like fatigue or a sore throat. Additionally, lymphadenopathy with mono is usually posterior.
• Bacterial lymphadenitis
  • Bacterial lymphadenitis is an infection of the lymph nodes, typically caused by bacteria, leading to inflammation and enlargement of the affected nodes. It usually occurs when bacteria invade the lymph nodes, either directly from a nearby infection (such as in the skin or throat) or through the bloodstream.
• Scrofula
  • Given the patient’s recent emigration from Pakistan, a TB-endemic area, this should be considered, particularly if there is lymph node enlargement without resolution and no response to conventional treatments.
• Lymphoma
  • Unlikely given the acute onset, lack of systemic symptoms (fever, weight loss, night sweats), and mobility of the lymph node, but still a differential if the lymphadenopathy persists or worsens.

Assessment 

• 17 year old female with no significant PMHx presented to urgent care today with complaints of tender cervical lymph nodes following symptoms consistent with viral/bacterial pharyngitis. Pt denies current constitutional or associated symptoms. On exam, a tender and enlarged R anterior cervical node was noted along with a tender L submandibular node. There was no erythema, warmth or drainage of the nodes. At this time there is no lab work or imaging to review. A clinical diagnosis of reactive cervical lymphadenopathy has been made.    

Diagnosis:

• Reactive cervical lymphadenopathy 

Plan

• Reactive cervical lymphadenopathy
  • Augmentin (amoxicillin-clavulanate) tablet 875-125 mg 1 tablet PO Q12H x10 days
    • Traditionally not requiring antibiotic treatment, however due to the large size and concern for bacterial superinfection, antibiotic treatment was started.
  • Supportive care
    • Warm compresses, ibuprofen/acetaminophen for pain, hydration, rest
  • Pt education
    • Explain what the dx is (enlargement of lymph nodes in the neck due to an immune response, typically to an infection or inflammation. The term “reactive” indicates that the lymph nodes are responding to a stimulus, such as a viral or bacterial infection, but are not diseased themselves.)
    • Return precautions- difficulty breathing, worsening of symptoms
    • Follow up with PCP if symptoms do not resolve and if lymph node remains enlarged with antibiotics, consider further work up for other ddx (ultrasound of lymph nodes, TB workup etc.).