Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New neck mass OR follow-up for known neck mass
(Specify) Describe the characteristics of the neck mass if known (e.g., size, location, duration, tenderness, mobility).
History of Present Illness:
Onset, duration, and any changes in the size or consistency of the neck mass.
Associated symptoms (e.g., pain, fever, night sweats, difficulty swallowing, hoarseness, weight loss).
Recent upper respiratory infections or other illnesses.
Past Medical History:
Underlying medical conditions (e.g., thyroid disease, lymphadenopathy from previous infections).
History of head and neck surgery, radiation therapy, or lymph node dissection.
Family History:
Family history of thyroid disease, head and neck cancers.
Social History:
Smoking history (smoking is a risk factor for head and neck cancers).
Physical Exam:
General examination: Assess for signs of systemic illness (e.g., fever, lymphadenopathy in other locations).
Head and neck examination:
Palpate the neck mass for size, location, consistency (firm, rubbery, cystic), tenderness, mobility (fixed or freely mobile), attachment to deeper structures.
Examine the thyroid gland for enlargement or nodules.
Assess for oral cavity lesions, enlarged tonsils, or other abnormalities.
Ear, nose, and throat (ENT) examination: May be performed if there are symptoms suggestive of upper airway involvement.
Imaging Studies:
Ultrasound of the neck: Initial imaging study to assess the characteristics of the mass (solid, cystic), identify blood flow within the mass, and evaluate surrounding lymph nodes.
Fine-needle aspiration (FNA) biopsy: Minimally invasive procedure using a thin needle to collect cells from the mass for microscopic examination. FNA can often distinguish between benign and malignant causes of neck masses.
CT scan or MRI scan of the neck: May be done if ultrasound is inconclusive or to further evaluate the extent of the mass and involvement of surrounding structures (e.g., muscles, blood vessels).
Laboratory Tests:
Routine blood tests (CBC, electrolytes) may be done to assess for signs of infection or inflammation.
Thyroid function tests: TSH, free T4 – to rule out thyroid problems as a cause of the neck mass.
Assessment:
Neck mass: Describe the location, size, consistency, and other characteristics of the mass based on physical exam findings.
Ultrasound findings (if performed): Solid or cystic mass, presence of vascularity, and lymph node involvement.
FNA biopsy results (if performed): Benign or malignant cells identified.
If malignant, specify the cell type.
Differential Diagnoses:
Consider a broad range of potential causes for neck masses, depending on the patient’s age, clinical presentation, and imaging findings. Common possibilities include:
Infectious: Lymphadenitis (swollen lymph nodes) from a recent infection (bacterial, viral)
Benign: Lipoma (fatty tumor), branchial cleft cyst, thyroglossal duct cyst
Malignant: Lymphoma, squamous cell carcinoma (of head and neck origin or metastatic to the lymph nodes)
Thyroid nodule: May present as a solitary nodule or multiple nodules within the thyroid gland
Plan:
The plan will depend on the suspected cause of the neck mass and findings from diagnostic tests. Possible elements include:
Observation: For small, non-tender, and likely benign masses with reassurance and follow-up.
Antibiotics: If an infectious cause is suspected.
Referral to ENT specialist: For further evaluation, surgical excision (if indicated), and potential need for additional treatment (e.g., radiation therapy for cancers).
Thyroid function tests and potential referral to endocrinology: If thyroid nodule is suspected.