Pediatric emergency medicine trisk 0947 0947

weight loss, night sweats, or adenopathy elsewhere are revealing. ENT and
respiratory symptoms such as noisy breathing (e.g., wheezing or stridor),
dyspnea, sore throat, and neck pain are likewise significant. Eliciting an exposure
history will further inform the differential. Temporal exposure to known sick
contacts, or recent trauma from animal scratches and bites can contribute to the
differential diagnosis. Antibiotic or antiepileptic drug exposure may cause
symptoms like serum sickness (e.g., fever, malaise, rash, arthralgias, nephritis) or
pseudolymphoma, respectively (see Fig. 48.1 ).
Physical Examination
The child presenting with a neck mass should have a thorough head-to-toe
examination, beginning with assessment for critical illness. A meticulous neck
evaluation may be deferred until after completion of the remaining examination.
Inspection of the oral cavity should describe structures such as oral mucosa,
dentition, Stensen duct (i.e., the parotid duct), and other glands. Movement of the
mass with swallowing or tongue protrusion is important to note. Further
inspection should include assessment of the scalp, ears, sinuses, and nasopharynx.
Evaluate remaining structures to determine if additional lesions are present.
The neck examination describes the location of the mass, including visual
inspection and palpation while in flexion and extension. Figure 48.2 diagrams
common locations of neck mass. Those in the supraclavicular area or the
posterior triangle (superior to the clavicle, and posterior or lateral to the
sternocleidomastoid), have a higher incidence of being neoplastic than those in
the anterior triangle (anterior or medial to the sternocleidomastoid). Palpation
provides critical characteristics of the mass including size, shape, consistency,
mobility, existence, and severity of tenderness. Presence of crepitation, thrill,
bruit, fluctuance, or overlying skin changes should also be noted. Characteristics
that may be associated with malignancy include masses that are firm, larger than
2 cm in diameter, nonpainful, progressively enlarging, ulcerating, deep to fascia
or fixed to tissue, longer duration (i.e., weeks), or discovered in a newborn. These
criteria are sensitive but not specific for cancer.