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The Art of Medicine

A lump in the neck

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: June 2020 - Volume 33 - Issue 6 - p 58
doi: 10.1097/01.JAA.0000662396.70650.d6
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The young woman is perched on the examination table; in a chair adjacent, an older woman with salt-and-pepper hair sits upright, knees together, purse clasped in her lap. I offer a hand to each one in turn and introduce myself.

“We've been coming here since she's a baby,” the older woman intones. “I don't recall seeing you before. Are you new to the practice?”

“Relatively,” I say. “I came on board 4 years ago. I gather that your daughter usually sees one of the woman doctors. Somehow she landed on my schedule today.” I offer a smile, then turn my eyes to the young woman. “I understand that you've got a lump in your neck. How long have you had it?”

“Maybe a couple of weeks; I'm not sure,” the young woman whispers.

“How did you discover it?”

“I felt it when I was taking a shower.”

“Does it hurt?”

The young woman shakes her head no.

“Have you been sick? Any unexplained fevers? Any weight loss?”

“No.”

“Can you show me where it is?”

The young woman points to the back of her head. The tip of her left index finger rests at the hair line. “Right here,” she says.

Gently, I palpate the back of her neck. A solitary small smooth rubbery mass slips between the pads of my fingers. I estimate it to be less than a centimeter in diameter. I examine the surrounding scalp, feel under her jawline, then check the base of the neck. Lastly, I ask the young woman to lie down. She hesitates, glances at her mother, then reclines on the examination table. I palpate the spleen, percuss the liver, then help her to sit up.

“It feels like a small lymph gland,” I say. “We call this a reactive lymph node. Nothing to worry about, really. It will subside with time.”

The young woman's eyes dart toward her mother. The older woman shifts slightly in her chair. “I'm afraid that I have to insist that you order an ultrasound study of the gland,” she says.

I pause with an inquiring look.

“You see, I was diagnosed with non-Hodgkin's lymphoma years ago. It started the same way, with a lump in my neck. I went to see my doctor, and he said the same thing. A couple of months later I went back; he told me not to worry. By the time I was diagnosed, I was in Stage 4.”

“How old were you then?”

“Thirty-eight.”

“And how old are you now?”

“Forty-eight.”

“So you've done well.”

“Yes, I'm a survivor. That's why I'd like to have the ultrasound study for my daughter.”

“Well, I can certainly understand your concern,” I say. “I could order an ultrasound of the gland, although truthfully, I'm not sure what additional information it would give us. The only way to establish a firm diagnosis would be to biopsy the node. I could refer you to a surgeon; but all told, I think we've got a pretty good idea of what we're dealing with—a small reactive lymph gland with all the characteristics of a benign node. I don't feel any additional nodes in the neck; the liver and spleen aren't enlarged; she's got no other signs of illness such as unexplained fevers or weight loss.”

Mother and daughter exchange glances. The young woman looks at the floor.

“I can see that you're worried,” I say, “so here are a couple of options. I can order the ultrasound if you'd like, or you can come back in a month and have the gland rechecked. If it's still a concern, we could always have you seen by one of the surgeons.”

“What would you like to do?” the mother asks the daughter.

“I'm okay with coming back in a month,” she says.

“All right,” the mother says. The phrase is short, clipped, terse. A momentary silence fills the room.

“She's due for her annual physical exam,” I muse. “If you'd like, you could probably schedule that with one of the women doctors and have the lymph gland checked at the same time.”

The mother's lips press tightly together, firmly sealed as the hasp on her pocketbook.

Establishing credibility is difficult in an initial encounter; the clinical waters have not yet been tested by time. In such circumstances, the best we can do is rely on our clinical expertise, offer a few options, then step back to permit the patient to weigh in.

Copyright © 2020 American Academy of Physician Assistants