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Probability diagnosis

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Localised infection e.g. tonsillitis, URTI, wound, skin

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Epstein–Barr mononucleosis

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Specific viral e.g. rubella, measles, Coxsackie

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Serious disorders not to be missed

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Infection:

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  • Septicaemia

  • HIV/AIDS

  • Tuberculosis

  • Syphilis, esp. secondary

  • Toxoplasmosis

  • Cytomegalovirus

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Cancer:

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  • Cellular: lymphoma, leukaemia, myeloma

  • Secondary metastatic nodes

  • Myeloproliferative disorders

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Pitfalls (often missed)

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Sarcoidosis

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Cat scratch disease

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Kawasaki disease

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Rarities:

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  • Tropical infections e.g. filariasis, plague

  • Localised STIs e.g. granuloma inguinale

  • Connective tissue disorders e.g. RA

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Masquerades checklist

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Drugs e.g. sulphonamides, phenytoin

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Key history

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Gather patient history of upper respiratory infection, lower respiratory infection, possible Epstein Barr infection, HIV, cytomegalovirus and other infections such as tuberculosis. Consider red flags such as weight loss, fever, night sweats, history of cancer and increasing size of lumps or lump. Note any response to antibiotics given for infection.

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Key examination

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  • General features: appearance of patient, vital signs esp. temperature

  • Palpate abdomen for evidence of splenomegaly and hepatomegaly

  • Note the consistency of lumps: soft, firm, rubbery or hard

  • Careful palpation of lymph node areas and matching the site of any lymphadenopathy with a map of areas drained by the nodes

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Key investigations

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First line:

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  • FBE

  • ESR/CRP

  • CXR

  • lymph node biopsy

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Consider relevant serology according to suspected infection:

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  • Paul Bennell test

  • syphilis

  • HIV

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