Case:
SUBJECTIVE:
CHIEF COMPLAINT: "I have noticed enlarging lumps in my neck for approximately two months."
HISTORY OF PRESENT ILLNESS: Mr. G.B. is a 49-year-old African-American male who was well until two months ago when he noticed nodular lumps on either side of his neck. These seem to wax and wane and fluctuate in size during this time. He had noticed some night sweats and a ten pound weight loss during this time. He had to change his dress at night at least a couple of times because of his night sweats.
PAST MEDICAL HISTORY: Essentially negative. He denied previous history of tuberculosis or exposure to other infectious disease.
PAST SURGICAL HISTORY: Right-sided inguinal herniorrhaphy and sebaceous cyst removal 20 years ago.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: One sister had uterine cancer. Parents died of old age.
SOCIAL HISTORY: He is married and lives with his wife and three children. He works in a steel factory as a shipper/receiver. He has a 20 packs per year history of smoking.
ETOH: Moderate use. He served in Viet Nam.
REVIEW OF SYSTEMS: Negative except for a ten pound weight loss, night sweats and poor appetite for the last two months. He denied any fever or chills.
APPEARANCE: General physical examination revealed a well-developed, well-nourished young black male in no acute distress. He weighed 160 pounds. Height is 5'8".
VITALS: His temperature 37.6EC. Blood pressure 140/80. Pulse of 88. Respirations 20.
SKIN: The skin: normal without any rashes, nodules or induration.
LYMPHATIC: There are palpable lymph nodes in the head and neck, cervical, supraclavicular, axillary, epitrochlear and inguinal areas bilaterally. These vary in size from 1.0 to 1.5 cm being the maximum. These nodes are firm in consistency, nontender, mobile and discrete. There are no signs of inflammation associated with these lymph nodes.
EYES: Conjunctivae are moist. The pupils are equal reacting to light. Extraocular movements are intact. He is not anemic nor jaundiced.
EARS, NOSE, MOUTH & THROAT: Examination of the external ears, nose, mouth and oropharynx is normal. The mucous membranes are moist without any lesions. The tongue, palate and gums are normal.
NECK: The neck is supple with palpable lymphadenopathy as described above, present both in the anterior and posterior triangles. The trachea is in the midline, the thyroid is not enlarged.
PULMONARY: Lungs are clear to percussion and auscultation bilaterally.
CARDIOVASCULAR: Heart exam reveals a regular rate and rhythm with a normal S1, S2, no S3, S4 or murmurs.
ABDOMEN: The abdomen is soft without tenderness, hepatosplenomegaly, ascites or other masses. He has normal bowel sounds.
GU: External genitalia is normal.
MUSCULOSKELETAL: Muscle mass, strength and gait are normal.
EXTREMITIES: Normal without any clubbing, cyanosis or edema bilaterally. The peripheral pulses are intact.
NEUROLOGIC: Cranial nerves II through XII are intact. His sensory and motor systems are normal. His deep tendon reflexes are normal and symmetrical bilaterally.
PSYCHIATRIC: He is oriented to time and place. His mood, memory and mental status are normal. He is highly anxious to find out what the problem is.
LABORATORY DATA: WBC 6.9, hemoglobin 13.7 and platelets of 339,000 with 60% granulocytes, and 23% lymphocytes, a few lymphocytes are abnormal with clefts. His SMAC reveals a BUN of 25 and creatinine of 1.2 an uric acid of 6.5. The rest of his SMAC was within normal limits. Chest x-ray showed bilateral hilar adenopathy.
ASSESSMENT: Generalized lymphadenopathy, etiology unknown.