<prompt> 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 -CT Scan of chestSputum exam. for AFBLaryngoscopy and chest x-rayExcision biopsy of the node  <response>: 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. 