Professional Documents
Culture Documents
2016-00448
ORL 260 Case Paper
Pertinent points in the history and physical exam alone
Detail Significance
Chief complaint of an anterior neck mass in a This would already narrow down our approach as
47/F certain pathologies would present in the anterior
neck. Women > 50 y/o are more at risk for
malignancy.
2 year history of gradually enlarging mass located This would tell us of the time course of the
in the left side of the neck, now 2.5 x 2.1 x 1 cm patient’s condition and also tell us where the
on PE mass began
Firm mass, no skin changes Classically, harder lesions and skin changes are
more associated with malignancy.
Non-tender, movable Non-tender masses are less likely to be caused by
reactive/inflammatory processes. The mass being
movable will also tell us about whether or not it
is invading deeper structures, which increases the
chances for malignancy.
(-) dyspnea, dysphagia, odynophagia, hoarseness It is important to rule out breathing and
swallowing difficulties due to mass effect from
the ANM.
(-) fever, weight loss, palpitations, tremors, hair These are symptoms of hyperthyroidism, which
loss, bowel movement changes must be considered if we are considering thyroid
pathologies
AD: Near total perforation with pale middle ear This would alert us to the possibility of the
mucosa patient having CSOM or other chronic ear
AS: Intact TM, no discharge diseases
Fully mobile vocal cords In the case we would need surgical management
for this patient’s mass, baseline documentation
of the patient’s vocal cord mobility is important.
We need to determine if there is recurrent
laryngeal nerve involvement. Involvement this
early on would raise suspicion for malignancy.
(-) cough, dizziness, BOV, headache, ear pain, Review of systems pertinent to ORL.
vertigo, diplopia
Palpable lymph nodes adjacent to the anterior
(-) palpable lymph nodes, oral cavity neck mass are more suspicious for malignancy.
masses/lesions, (-) nasal
masses/bleeding/deviation
No PMHx of HPN, DM, asthma, TB, allergies These comorbidities may affect management
FMHx of goiter in the mother Goiters may have a hereditary component, and
may also reflect iodine deficiencies in families
No vices, no exposure to radiation Smoking, alcoholism, and illegal drug intake may
affect our approach and management. Exposure
to radiation may increase the risk for malignancy.
Smoking and alcoholism may reduce the risk for
thyroid malignancy.