A CASE OF SWELLING IN THE NECK

 Fousiya, 54 year old,house wife,Manjeri

CHIEF COMPLAINTS
 Swelling on right side of neck -3 months
History of present illness

 The patient was apparently normal 3 months back

 Then she noticed a swelling on the right side of neck .
 Initially the swelling was small and it gradually increased in size to reach the
present size
 The swelling was initially painless now there is pain for the last 1 week
 No h/o ulceration or discharge
 No history of difficulty in moving neck,neck pain
 No visible swelling in other part of body like axilla ,groin ,back of knee, around
elbow.
Ctd ……..

 Patient also complains of an evening rise of temperature for last 1 month

 Night sweat is present
 No history of significant weight loss
 No h/o chest pain,cough,hemoptysis, dyspnoea
 No h/o bleeding from nostrils,ear pain ,ear discharge
 No history of fever,sore throat
 No history of repeated infections
 No history of bleeding tendencies
 no history of any breast lesion,discharge from nipple
 No history of abdominal pain ,back pain
Past history

 No relevant past medical or surgical history

 No h/o any other swelling in the body
 She is diabetic for the past 4 years and is on medication. No h/o hypertension
,dyslipidemia. No other medications are being taken
 No h/o pulmonary tb
Family history

 Husband’s sister has h/o pulmonary TB she has completed her treatment for TB
and is presently asymptomatic. They live in the same house.
 No other members in the family has a history of TB
 No history of malignancy running in the family.
Personal history

 Normal sleep and apetite

 Normal bowel and bladder habits
 Mixed diet
 No addictions:smoking,tobacco
Socio economic status

 Lower middle class family

 Family of 6 members with one earning member
 Proper ventilation and sanitation present
General examination

 Consious & cooperative

 Well oriented in time place person
 Moderately built and nourished
 BMI 20
 No pallor , icterus, cyanosis, clubbing
 No generalised lymphadenopathy
 No edema
 Vitals
 Pulse 72/min regular normal Volume and character, no vessel wall thickening no
radio-femoral or radio radial delay
 Bp 110/70 mmHg right arm sitting position
 Respiration 14/min ,thoraco abdominal
 Temperature afebrile
 Skin, hair,nail normal.
 Examination of breast normal.
Examination of neck
 A.INSPECTION
 A single , round swelling of size about 3*4 cms found on the right side of the neck
in the supraclavicular area between the two heads of sternocleidomastoid muscle
 The surface of swelling is smooth and edges are well defined
 Overlying skin is red and oedematous
 No ulceration or discharge
 Swelling is non pulsatile
 No Visible swelling of thyroid
 No dilated vein of chest wall or face
 B.PALPATION
 local rise of temperature is present
 A single round swelling of size 3*3.5 cms palpable on the right side of Neck 1
cm above the middle of clavicle and 5 cms lateral to the midline of neck
 Mild tenderness over the swelling
 Swelling is smooth ,soft , fluctuant,non transilluminant with restricted mobility
and no fixity to the overlying skin
 Swelling is non pulsatile
 Margins are well defined and regular
 Trachea midline
 Common carotid artery pulsation normal
 Thyroid gland not palpable
Examination of drainage area

 Scalp normal
 Oral cavity-lips,tongue,buccal mucosa normal.
 Nasopharynx ,tonsil, head and nasal cavity normal with out any infection
 No dental carries
 No ear discharge or pain
 No swelling or pain of thyroids
 No paranasal sinus tenderness
 Other lymph nodes : axilla groin , in the back of elbow is not palpable
Systemic examination

GIT
 Shape of abdomen normal ,umbilicus central and inverted
 No visible swelling or pulsation
 No abdominal tenderness.
 No hepatosplenomegaly
respiratory system ; normal vesicular breath sounds,
no added sound
CVS : S1 S2 heard no added sounds no murmur
CNS :within normal limits
Summary

 54 year old female patient hailing from a lower middle class family Who is diabetic for the past
4 yrs and is on medication with a family history of pulmonary TB in her sister in law who has
completed her treatment for TB and is presently asymptomatic Presented with swelling over the
right side of neck for past 3 months that gradually increased in size and pain and redness over
the swelling for 1 week duration.
 She has associated evening rise of temperature and night sweats for the past one month . No h/o
significant wt loss
 On examination a single round swelling of size 3*3.5 cms palpable in the right side of Neck 1
cm above the midpoint of clavicle and 5 cms lateral to the midline of neck. There is local rise of
temperature and mild tenderness
 The swelling is smooth,soft, fluctuant,non transilluminant.non pulsatile, with restricted mobility
and no fixity to the overlying skin.
 No other palpable lymph nodes elsewhere in the body
Provisional diagnosis
 Tuberculous cold abscess of the neck complicated with a secondary infection

DIFFERENTIAL DIAGNOSIS
 Secondary in the supraclavicular lymph node from an unknown primary
 Infected sebaceous cyst