Presenting History
In adolescents and children presenting with progressive lymphadenopathy, characterize the node enlargement, meticulously elicit constitutional B-symptoms, and vigilantly screen for anterior mediastinal airway compromise.
- Lymph Node Progression:
- Site of Onset: Did the swelling begin in the cervical, supraclavicular, axillary, or inguinal regions?
- Painless Nature: Has the lump remained painless and non-tender without skin redness or discharge?
- Chronicity: Has the swelling persisted and steadily enlarged over $>4-8$ weeks?
- Constitutional 'B-Symptoms' (CRITICAL STAGING CRITERIA):
- Fever: Is there unexplained recurrent fever $>38.0^\circ\text{C}$? Does it follow the cyclical Pel-Ebstein pattern (several febrile days alternating with afebrile weeks)?
- Night Sweats: Are there drenching night sweats requiring changing of clothes or bed linen?
- Weight Loss: Has there been unexplained loss of $>10\%$ of total body weight over the preceding 6 months?
- Mediastinal Compression & Airway Symptoms:
- Is there a dry brassy cough, wheezing, orthopnea, or breathlessness while lying flat?
- Does the child prefer sleeping propped up on pillows?
- Has there been facial puffiness, fullness in the neck, or bluish discoloration of the face?
- Systemic Symptoms:
- Is there generalized persistent itching (pruritus) without skin rash?
- Any abdominal distension, fullness, or bone pain?
Negative History (3C 1D Framework)
| Category | Pertinent Negative Question | Rationale / Significance |
|---|---|---|
| Causes | Tuberculosis Contact: No history of close contact with an adult pulmonary TB patient; no unpasteurized milk consumption. | TB lymphadenitis is the chief infectious mimic in endemic areas. |
| Complaints (Differentiating) | Pyogenic Adenitis: No acute onset, exquisite tenderness, overlying redness, or warm fluctuance. Cat Scratch Disease: No history of kitten scratch or primary skin papule. Infectious Mononucleosis: No acute exudative pharyngitis with severe sore throat. | Pyogenic nodes are acute and tender. Bartonella causes subacute regional adenopathy. EBV infectious mononucleosis causes acute generalized adenopathy. |
| Complications | Superior Vena Cava (SVC) Syndrome: No facial chemosis, cyanosis, distended chest wall collateral veins, or inspiratory stridor. Spinal Cord Compression: No lower limb weakness, sensory level, or urinary retention. | Critical oncological emergency requiring immediate cytoreduction. Paraspinal tumor extension through intervertebral foramina. |
| Differentials | Acute Leukemia: No triad of tri-lineage marrow failure (petechiae, severe pallor, nocturnal bone pain). | Differentiates lymphoma from leukemic nodal presentation. |
Other Relevant History
- Biopsy History (CRITICAL VIVA TRAP): Ensure NO Fine Needle Aspiration Cytology (FNAC) was performed; confirm whether an intact excisional biopsy is planned.
- Family History: Document history of lymphoma, leukemia, or autoimmune disorders in relatives.
History Summary
"Master/Miss `Patient Name`, a `Age` old `male/female` child, `Birth Order` born of a `consanguineous/non-consanguineous` marriage from `City, State`, presented with a `Duration in weeks` history of painless, progressively enlarging right/left cervical and supraclavicular lymphadenopathy, accompanied by classic constitutional B-symptoms (Pel-Ebstein fever, drenching night sweats, and $>10\%$ weight loss) and dry cough on lying supine, in the absence of tuberculosis contact or cytopenic bleeding.
I would like to consider a provisional diagnosis of Malignant Lymphoma (most consistent with Hodgkin Lymphoma, Cotswolds Stage II-B), with suspected anterior mediastinal lymph node involvement."
General & Head-to-Toe Examination
- General Appearance: Alertness, respiratory posture (check if child tolerates lying flat vs sits upright in tripod position).
- Vitals: Heart rate, respiratory rate, blood pressure, temperature (document current febrile/afebrile cycle).
- Anthropometry: Weight (calculate exact percentage weight loss over baseline), height, BMI Z-score.
- Detailed Lymph Node Basin Examination:
- Examine all superficial lymph node chains: Cervical (anterior, posterior, submandibular, submental), Supraclavicular (Virchow's node), Axillary, Epitrochlear, and Inguinal.
- Document for each chain: number, size of largest mass in cm, firm-to-rubbery consistency, discrete vs matted nature, mobility, and complete absence of tenderness or warmth.
- Assessment for Superior Vena Cava / Mediastinal Syndrome (SMS):
- Inspect face and neck for facial plethora, periorbital edema, and conjunctival suffusion.
- Check neck and upper anterior chest for visible dilated, tortuous venous collaterals.
- Auscultate over larynx and trachea for inspiratory stridor.
Systemic Examination
Respiratory System & Mediastinum
- Retrosternal Dullness Test: Percuss directly over the manubrium sterni: dullness extending beyond the sternal margins indicates an Anterior Mediastinal Mass.
- Auscultate lungs: check for localized wheezing from bronchial compression or absent breath sounds from pleural effusion.
Abdomen
- Palpate for Hepatosplenomegaly (measure cm below costal margins) and intra-abdominal masses or mesenteric adenopathy; rule out ascites.
Neurological System
- Sensorium, cranial nerves, motor power, deep tendon reflexes, and plantars (rule out spinal cord compression).
Final Summary & Diagnosis
"A `Age` old `male/female` adolescent presenting with an insidious `Duration` history of painless rubbery lymphadenopathy, with physical examination confirming discrete, firm, rubbery, non-tender `Cervical/Supraclavicular` lymphadenopathy measuring `Dimensions`, manubrial percussion dullness suggesting mediastinal widening, documented constitutional B-symptoms (`Weight loss %`), and absence of SVC syndrome or peripheral cytopenias.
My final clinical diagnosis is Hodgkin Lymphoma, clinically Ann Arbor / Cotswolds Stage II-B, requiring urgent erect chest radiograph, excisional lymph node biopsy with IHC (CD15, CD30), and whole-body 18F-FDG PET-CT staging."