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== Clinical Summary ==
The patient is an 80 60 year old male who presented to the Emergency Department with a chief complaint remote history of right flank an abdominal melanoma that was excised with negative margins. The patient has been experiencing lower back painfor the past several months and has received epidural injections. He described the pain as As a 10/10 pain in his right flank. He denied any associated symptoms with this pain. He denied constipation, cough, shortness part of breath, fever, dysuriathe workup, hematuria, nausea, or diarrhea. He could not identify anything that made the pain worse or betterpatient had a CT which revealed retroperitoneal lymphadenopathy. He did take 5mg A CT guided fine needle aspiration and biopsy of acetaminophen-hydrocodone and did not have any relief. He had just taken his evening medications when the pain began, and he can not identify any activity that may have caused the paina paracaval lymph node was performed.
=== Past Medical History ===
* Chronic obstructive pulmonary disease2003 Melanoma* Allergic rhinitisDiabetes
* Hypertension
=== Past Surgical History ===
* 1993 Disk arthroplasty2013 Arthroscopic knee surgery* 2002 Coronary artery bypass with grafting2003 Excision of melanoma* 2009 arthroplasty* Cholecystectomy year unknown2002 Discectomy
===Clinical Plan===
==Radiology==
* PET CT scan revealed multiple lytic showed hypermetabolic activity with an SUV of 12.7. * CT of abdomen and sclerotic lesions within pelvis showed adenopathy adjacent to the thoracolumbar spine aorta and sacrum. These were thought inferior to be suspicious the vena cava at the level of metastatic disease. Wall thickening in the descending colon was seen and was thought to possibly represent a primary colon cancerright kidney. The prostate was enlarged. The clinicians decided to perform a CT guided biopsy and a touch prep was made for rapid interpretation by the Cytology teamlargest node measured 4 cm in greatest dimension.
===CT===
====Resident Questions====
* <spoiler text="Benign or malignantWhat is your differential diagnosis?">These groups of cohesive cells are larger than the normal elements we would expect to find demonstrate malignant appearing cells in a touch prep from a spinal biopsybackground of an otherwise benign appearing lymphoid background. ThisThe atypical cells are scattered, along with large nucleoli and several binucleate forms. In addition, there seem to be an increased number of eosinophils in the patient's historybackground. The differential diagnosis includes Hodgkin lymphoma; however, should make you think that there is a malignant process involving the spinepossibility of the large atypical cells being melanoma cannot be ruled out.</spoiler>
* <spoiler text="What would you call this on a Rapid Interpretation?">This is a male patient with no previous history of malignancy. Our differential diagnosis can include many entities. However, these are cohesive cells so lymphoma should be at the bottom of our list. We would need more information to classify these cells, but a diagnosis of positive for malignancy (with no further specificity) can be rendered.</spoiler>