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Snapshot diagnosis - what's the swelling in this man's armpit?

Does this firm mass have a neoplastic or infective cause? Dr Mike Wyndham describes a case

Does this firm mass have a neoplastic or infective cause? Dr Mike Wyndham describes a case

The patient

This 85-year-old really hadn't been coping recently and had loss of appetite and a reduced mobility. His past medical history was pretty minimal apart from an appendicectomy 60 years earlier.

He was not taking any medication. He'd stopped smoking 15 years earlier. A carer noticed a swelling in his right armpit. It felt like a firm mass.

First instinct

The size of the swelling suggested something fairly dramatic and the consistency was worryingly firm and hard. The position suggested that this was lymphadenopathy.

Differential diagnosis

When considering the cause of lymphadenopathy in this age group, likely diagnoses are:

• infection, such as TB

• neoplastic, for example leukaemia, lymphoma, metastatic cancer.

Further examination revealed very little. There were no other palpable glands, his chest was clear and his abdomen felt normal. His skin was lax in places, confirming weight loss. His mental test score was very good.

I explained he needed to have some further investigations. I also suggested food supplements to see if we could increase his calorie input – and wrote a prescription.

Getting on the right track

As I handed it to him my eye was drawn to his fingers. His fingers were clubbed, suggesting lung cancer. His blood tests came back showing a normochromic normocytic anaemia and his ESR was 95. His biochemistry was normal apart from a mildly raised urea compatible with his age. His chest X-ray showed a mass at the right hilum – highly suggestive of lung cancer.

He agreed to a biopsy of his lymph node mass. The histology was highly suggestive of metastases from lung cancer. He refused all further treatment and died peacefully six weeks later from a bronchopneumonia.

Dr Mike Wyndham is a GP in Edgware, north London

• Submit your pictures

Have you got a photo of an odd clinical case that turned out not to be what it first seemed? Submit your photo together with the case history and key learning points. The best will win a case of wine and a selection will be published in Pulse. Deadline 30 January.

For more information contact Pulse's clinical editor Adam Legge at alegge@cmpmedica.com or on 0207 921 8097.

What's the swelling in this man's armpit? What's the swelling in this man's armpit?

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