DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Left neck swelling.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who was seen by his nurse practitioner, who sent him here for further evaluation. He states he has noticed a painful, swollen area in his left supraclavicular region near the left side of his neck for the past two to three days. He states he has not noticed this before this. He states it is worse when he raises his left upper extremity. He denies any trauma to the area. The patient denies any fever, chills, nausea, vomiting or diarrhea. The patient denies any recent lethargy, fatigue or weight loss. The patient denies any other illness-type symptoms. He has no complaints of a sore throat.
PAST MEDICAL HISTORY: No major illnesses.
ALLERGIES: Penicillin.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: The patient denies tobacco use, admits to occasional alcohol use.
REVIEW OF SYSTEMS: Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.4, pulse 88, respirations 20, O2 saturation 98% on room air, and BP 130/74.
GENERAL: The patient does not appear acutely ill. He is very pleasant.
HEENT: Normocephalic and atraumatic. Extraocular movements are intact.
NECK: There is some neck swelling at the anterolateral base of the neck on the left side. There is obvious supraclavicular mass in this location that is slightly tender to palpation; it is very firm. There is some slight ecchymosis noted over this area. There is no erythema. The rest of his left and right proximal neck shows really no other significant lymphadenopathy.
CHEST: Nontender.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nondistended, positive bowel sounds, no obvious masses noted.
EXTREMITIES: Specifically, his groin and axilla show no other significant lymphadenopathy. His extremities had full range of motion.
SKIN: Shows no evidence of rash.
NEUROLOGIC: Completely intact.
EMERGENCY DEPARTMENT COURSE: A CT of the neck with IV contrast was obtained to evaluate this left supraclavicular mass. He was noted to have massive lymphadenopathy in the left supraclavicular region with a 2.6 x 2.0 cm cystic area that was felt to be an infected lymph node. He was also noted to have impressively widened mediastinum and was noted to have multiple superior mediastinal lymph nodes noted on this scan as well.
White count was 13.6, hemoglobin 13.4, hematocrit 41.0, 1% bands, 76% neutrophils, 16% lymphocytes. Glucose 82, BUN 10, creatinine 0.7, sodium 138, potassium 4.3, chloride 99, and CO2 30.
The patient was given Ancef 2 grams IV. We did spend a tremendous amount of time talking to him and his wife about the possibility of a lymphoma or some type of cancer as the etiology of his lymphadenopathy, both in his left supraclavicular region and in his mediastinum.
We did speak with Dr. John Doe. He would like us to send him home with some antibiotics and something for pain, and he will follow him in the office on Tuesday and make sure he gets appropriate referral to an oncologist.
IMPRESSION: Acute left supraclavicular lymphadenopathy with mediastinal lymphadenopathy.
PLAN:
1. Follow up with Dr. John Doe.
2. Will get referral to oncology.
3. Given a prescription for Keflex and Lortab 5, #10.
4. Return as needed.
