- A 24-year-old came to the office with a nearly
golf ball-sized mass in her armpit.
Here's what happened next.
(upbeat music)
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 four 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 symptom-wise,
I then need to know what the mass actually looked like,
what it 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 ask 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 appearance.
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.
She's healthy, takes no medications, no allergies.
I ask how she's feeling about this mass,
and I saw that she was having some anxiety about it
and 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, 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 the lymph nodes
to swell, and that area has several lymph nodes in it.
Then, I asked about recent injuries or cuts
because any time 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 breasts 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
'cause 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, and at this point, I was so puzzled.
I'm like, I feel like 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 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 ultrasounds,
other imaging to figure out what this mass is.
Option B, we take 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 'cause 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 unless they're like totally huge,
is if they're persistently swollen,
and persistently is kind of tricky in medicine
'cause there's no like, oh, if it crosses four weeks,
then that means 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 COVID-19.
So I ask 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 effect.
It should be called intended effect 'cause we want you
to have an immune response to the vaccine.
It 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 COVID 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 gonna 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 timeframe that we expect it
to begin shrinking after the vaccine,
and ta-da, no more palpable lymph node.
The golf ball mass was gone.
(upbeat music)
Victory.
All that goes to show is how important a full 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 reason X, Y and, Z?
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'll happen
is the doctor will 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 911 call for a heart attack.
Click here to check out that story,
and as always, stay happy and healthy.
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