I recently had a patient encounter that threw me for quite the loop. While precepting for my residents, we encountered a patient ...

my-patient-thought-it-was-cancer

My Patient Thought it was Cancer…

a 24 year old came to the office with a nearly golf ball-sized mass in her armpit here's what happened next so I'm working in my family medicine office where I'm actually precepting which means that I'm not seeing patients directly I'm actually overseeing residents seeing their own patients what does that mean though it means that the residents after seeing the patient creating a plan come to me tell me about the patient tell me about the plan perhaps ask for advice I give feedback I give guidance sometimes I go in to see the patient if there's a procedure that needs to be done I can help teach the resident how to perform that or perhaps just be an observer to make sure that everything is done correctly one of the residents comes in to present the case of a 24 year old female with a nearly golf ball-sized mass in the armpit now the resident does a good job presenting telling me the history how long it's been there about five days it's quite painful initially but now has subsided still about a 4 out of 10 in pain it's present all the time it hasn't gotten bigger it hasn't gotten smaller since the time that it's been there I then asked the resident what was the physical exam like because after we get the physical and understanding of what's going on with the patient's symptom-wise I then need to know what the mass actually look like what it fell felt like on an objective exam the mass was anywhere from two to three centimeters it was mobile it was round it was well circumscribed meaning that they could feel it exactly as it is it wasn't very superficial so it wasn't like right there in the skin layer they did say it was somewhat tender now the reason we asked these questions and make these assertations is because we're trying to distinguish between a suspicious dangerous red flag mass and one that is more benign appearing the area where it's in is quite tricky because when we're thinking as doctors of the area where a mass appears we have to think about the entire Anatomy nerves muscles skin features each layer of the skin hair follicles even lymph nodes which is part of your immune system so we're trying to think why does this Mass appear here where it does not belong so I decide to go into the room and see the mass for myself I ask a few questions about her health uh she's healthy takes no medications no allergies I ask how she's feeling about this mask and I I saw that she was having some anxiety about it I knew we needed to address that I then proceed to do the physical exam and it's exactly as the resident stated that it was it had some suspicious features some benign features and at this point like I'm getting kind of confused and worried at the same time because I don't have a good reason as to why this 24 year old healthy person would have this Mass on them I knew I needed to ask more questions the first question that I asked was about family history to see if there was any cancers or autoimmune diseases like lupus that ran in the family that can cause lymph nodes to swell then I asked about recent illnesses because viral infections can also cause lymph nodes to swell and that area has several lymph nodes in it then I asked about recent injuries or Cuts because anytime you have a cut or an infection you can actually get lymph nodes to swell as a result of the inflammation then I asked about skin rashes because we always have to not forget fungal infections and allergies which could present initially as rashes then I asked about breast symptoms like lumps or pain in the breast because we need to not forget that while this is a young patient breast cancer is still technically on the differential diagnosis until I ask further questions then I asked a question about shaving and the patient actually laughed but the reason I ask about shaving is because frequent shaving of the armpits can actually cause the hair follicles to get blocked thereby causing folliculitis that then can turn into an abscess if it doesn't clear itself she doesn't shave so that wasn't it either I then proceeded to ask about recent blood work because if she had a CBC done which is a complete blood count I could then see if there was any abnormalities on the white blood cell count which could signal a potential leukemia or lymphoma we don't want to miss this just because I don't expect this to be the main diagnosis guess what four weeks ago she had a physical with normal blood work and no issues on the CBC then I go ahead and ask about vaccines with her physical because as we know certain vaccines can cause lymph node swelling and she did admit to getting a tetanus shot in one arm and an HPV vaccine in the other arm and I came to the realization that it's probably not it because it was like four or five weeks ago and by that time the lymph nodes should have went back down if they were inflamed as a result of the vaccine at this point I was so puzzled I'm like I feel like I I've asked every question and I needed to do a timeout no joke I actually said to the patient hold on a second let me let me take a second and I like being open with patients I like them to see the process of me thinking this through when you could be open and say like honestly I don't know what's going on right now let me weigh the pros and cons it creates a level of trust so I tell the patient okay here's my options option A we proceed as if this is a true suspicious Mass we start doing more tests we start ordering ultrasound to other Imaging to figure out what this mass is option b we take it a watchful waiting approach we see if the mass changes over the next two weeks if it doesn't we watch it and see if it shrinks and goes down by itself like most lymph nodes do the reason they're there is to clean up some of this debris to help your immune system function and they do shrink and grow as a result of inflammation so just because you have a swollen lymph node doesn't automatically mean you have a problem so the only time we really worry about lymph node swelling albeit it unless they're like totally huge is if they're persistently swollen and persistently it's kind of tricky in medicine because there's no like oh if it crosses forward weeks and that means like you've crossed the line there's a little bit of clinical flexibility there so I talk about this with the patient and then it hits me we're in the middle of the pandemic I'm asking people to get vaccinated for covet 19. so I asked the patient hey did you get vaccinated for covid-19 and she goes oh yeah three days ago which arm that arm the same arm where she's having those symptoms one of the side effects of getting the covid-19 vaccine is swollen lymph nodes in fact this shouldn't be called side effects it should be called intended effects because we want you to have an immune response to the vaccine that means your immune system is prepping to meet the real thing and fight it off so the lymph node swelling is actually a good thing it's only problematic when it causes anxiety or causes you to have a false positive on a mammogram that's why I'm telling you right now if you get your coveted vaccine make sure you wait four to six weeks after to get the mammogram we suspected that this was the cause of her lymph node swelling we told her that we're going to create this plan that in two weeks she will come back we will check make sure that the lymph node is not there anymore because that's the time frame that we expected to begin shrinking after the vaccine and Tada no more palpable lymph node the golf ball Mass was gone Victory all that goes to show is how important a full hist history and full physical is to making a diagnosis if a doctor ever ignores one of these parts that should be a big warning sign a lot of patients ask when should I go seek help for a reason X wines if you're thinking about it do it if you ever have a mass that you're concerned about that's the time you go see your doctor because the worst thing that will happen is Doctor tell you you're all good that's a good feeling too as seen here medical cases aren't always straightforward as seen here sometimes they start with foot pain and then a 9-1-1 call for a heart attack click here to check out that story and as always stay happy and healthy foreign

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