sunny2
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53 years old but looks very young Carla Hamolka has a mass in her right axilla, the mass is hard ,2cm movable. BP 130/90, pulse 82, RR 12 ,Past history of cough, fever off and on ,seasonal allergic rhinitis and an episode of cat scratch diesease. Abdomen is soft, neurological examination is unremarkable ,breast examination is negative and she has no enlarged lymphnodes anywhere else . The next best step in management is :
1.Chest X-ray
2.Mammogram
3.Lymph node biopsy
4.Routine Blood test
5.Allergy test
6.Excisional Biopsy
7.Warthin starry stain
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| Jinx
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ill go 4 mammogram
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| sunny2
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Jinx....Mammogram..for what ??!!
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| Jinx
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well i went for that mainly based on age
the node could be reactive--tho u say its hard suggesting malignant--so mebbe watch b4 biopsy??--but that wasnt an option..
episode of cat scratch disease--is that past or present?(i wasnt sure readin the question) if present--course of azithro
so mammography--as screening
besides--if it picks up anything--sample the lymph node
thats what i thot--but judging by ur reply, im totally outta my depth--so whats the answer??
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| study_ing
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i went for mamo too. axillary mass, with physical findings suggestive of cancer, id look for the primary in the breast....and u need a baseline one done any way. but since i stil havent studied the topic and am relying on instinct i cud be wrong. my second choice wud be an excisional biopsy. the histo wud gude us to the primary etiology and if neoplastic, perhaps a source.
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| sunny2
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Jinx and study_ing
yes, this is a potential presentation for cancer of the breast, in a younger person you would think of lymphoma and it could still be lymphoma on her. She needs a mammogram because we are looking for an occult primary and that node will eventually have to be biosied.
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| robin082006
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| study_ing
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agreed. though cud anyone expand on y mammo first and then biopsy rather than the other way round..
is it coz of invasiveness?
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| tolito
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yes, study-ing. i would say the normal principle is to go first for a non-invasive test before the invasive. the node is likely to be a seconday. her age also makes her a high risk for breast ca. question is tricky cos you will have to biopsy the lymph node anyway but i would like to confirm that the primary is in her breast.
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| tolito
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hey, substitute 58 for the woman's age and take away the rest of the question from BP onward and it becomes a kaplan vignette in surgery....no 14 under breast. answer is mammo.
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| frank100
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mammogram
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| sunny2
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tolito, indeed it's from kaplan, i was just going thru the vignettes and thought of twisting this up as it seems important for exam.
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| AAAAA
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sunny2 wrote:
53 years old but looks very young Carla Hamolka has a mass in her right axilla, the mass is hard ,2cm movable. BP 130/90, pulse 82, RR 12 ,Past history of cough, fever off and on ,seasonal allergic rhinitis and an episode of cat scratch diesease. Abdomen is soft, neurological examination is unremarkable ,breast examination is negative and she has no enlarged lymphnodes anywhere else . The next best step in management is :
1.Chest X-ray
2.Mammogram
3.Lymph node biopsy
4.Routine Blood test
5.Allergy test
6.Excisional Biopsy
7.Warthin starry stain
mammography---even mammo is negative, you still need a sentinal biolpsy so 2 first then still need 3
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| tolito
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good question
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| cbenitesch
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Could you compare the specificty and sensibility of a mammogram vs a lymph node biopsy?!, If you are suspecting on cancer!!!... why mammogram having a 2cm axillary mass!!!!!.... Please read First Aid for Usmle2 on page 352 on evaluation, and think about your question! 
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