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Clinical presentation A 30 year old fisherman was admitted to the medical ward at Queen Elizabeth Central Hospital, Blantyre as a referral from Chikwawa District Hospital with a one year history of cough, painful throat, hoarse voice and difficulty swallowing. The cough was productive of cream colored sputum with no blood staining. There were no relieving or exacerbating factors and there was no diurnal variation in the intensity of coughing. He also had a sore throat and chest pains which were burning in nature. Five months after the onset of the cough he developed hoarseness of voice which became progressively worse. He experienced a “burning sensation” when speaking. Within this period, he also developed pain and difficulties in swallowing both solid foods and water. Dysphagia for fluids started at the same time as dysphagia for solids. Three months prior to admission, the patient noted that there was slight protrusion of his throat which was tender on touch. He also had a sensation of a rough mass in his throat and hence could often clear his throat. He had a history of intermittent night sweats, fevers and weight loss, which he was not able to quantify. He also described dyspnoea on exertion. However, he had normal appetite, no abdominal pains and normal bowel habits. There was no history of ear pain or TB contact. The cough had not responded to Amoxycillin and Erythromycin which had been prescribed by a local health centre in his area. He never smoked nor took any form of alcohol. However, for many years he had worked as a fish smoker. On examination, he was, alert with a fair nutritional status and not in obvious respiratory distress. The conjunctivae were pink and there was no jaundice. There was no finger clubbing. He was afebrile with a temperature of 36.8 °C , pulse rate 80/ min, respiratory rate of 20 breaths/min and a blood pressure of 110/70 mmHg. He had a hoarse voice and was often clearing his throat and coughing. The cough had a “bovine” quality. The uvula was not deviated and there was normal movement of the pharynx, normal sensation in the oropharynx, an intact gag reflex and no stridor was heard. He had bilateral cervical lymphadenopathy in the posterior triangle of the neck. The lymph nodes were mobile, not matted, with sizes ranging from 0.5-2cm in diameter. Bilateral crepitations were heard on chest examination. The cardiovascular and abdominal examinations were unremarkable. Questions 1. Based on the history and examination described above what are the important differential diagnoses to consider? 2. What investigations should be done? The important diagnoses to consider are either; • Malignant process • Infectious process Theresa Allain1, Kondwani Katundu1, Wakisa Mulwafu2 1.Dept of Medicine College of Medicine, University of Malawi 2.Dept of Surgery College of Medicine, University of Malawi

Ward Round – Cough, painful throat and progressive hoarseness of voice for 1 year