This is a real-world medical entrance exam question, please give the true answer based on the question and selection. Topic name: None, Subject name: Surgery
55 year old chronic smoker presents with complaints of hoarseness of voice, and single enlarged painless lymphnode in left supraclavicular region. Next step to be done - 
Select and explain. 
A. CT Scan of chest, B. Sputum exam. for AFB, C. Laryngoscopy and chest x-ray, D. Excision biopsy of the node
D: Excision biopsy of the node
Answer: D: Excision biopsy of the node 
Explanation: Ans. is 'd' ie. Excision biopsy of the node Pts age and history of chronic smoking & hoarseness are pointing towards laryngeal cancer & lung cancer (lung cancer can cause hoarseness of voice by involving the recurrent laryngeal nerve). But laryngeal cancer does not drain to supraclavicular lymph node. So no need of doing a laryngoscopy. Supraclavicular lymph node drains from following areas ? a Retroperitoneal space d testis b Lung e ovaries c breasts f GIT. An enlarged supraclavicular lymph node is always abnormal, so whenever we find one we do an excisional biopsy to know the histology (it would point towards the primary cause). Harrison writes - " The indications for lymph node biopsy are imprecise yet it is a valuable diagnostic tool. The decision to biopsy may be made early in a pts. evaluation or delyayed for upto 2 weeks. Prompt biopsy should occur if the pts. history and physical finding suggest a malignancy, examples include a solitary hard, nontender, cervical node in an older pt. who is a chronic user of tobacco; Supraclavicular adenopathy and solitary or generalized denopathy that is firm, movable and suggestive of lymphoma."