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Cases ...

Chest/Pulmonary Student Handout 1

     Student Handout IPC Block 5

    Diagnostic Testing and Medical Decision Making

    August 2007

    Week 6: Chest/Pulmonary

    Note to students:

Recommended reading from Mettler Radiology text, “Essentials of Radiology”:

    Chapter 1: Introduction to Radiology (if not already read)

    Chapter 2: Chest

    Please review the cases below and prepare the answers for small group discussion.

    Images are available for review on Blackboard prior to the sessions. (Note: Some images

    on Blackboard will not be included in your questions, and will be used for further

    discussions during small group sessions.)

    Additional resources: Medical Imaging by Peter Scally (1999). (On reserve in the library and on PBL shelves.)

Case 1

A wife brings her 66-year-old husband to clinic because she is worried about possible weight loss and

    decreased level of activity over the last few months. He says that he feels fine, although he acknowledges

    his appetite is a little decreased, and a recent 5-day history of mild shortness of breath and minimal

    hemoptysis. His wife was recently treated as an outpatient for bronchitis that seemed to resolve. His past

    medical history is significant for gastro-esophageal reflux disease and mild osteoarthritis. He takes an

    ASA 325mg per day and ranitidine 150 mg BID.

1. What other information would you like to know?

Do you have a family history of cancer?

    Have you been around anybody with TB?

    Do you smoke?

    Nature of dyspnea? Onset of dyspnea (exertional or at rest)? What makes it better or worse?

    Have you had any cough, atelectasis, postobstructive pneumonia, or wheezing?

    Do you take any illicit drugs (crack cocaine can cause hemoptysis)?

    social hx; occupation; vitals; physical; other sick contacts; nature of hemoptysis (color of blood dark or

    bright); other GI issues

Examination:

    VS: Wt=172 lbs P = 78 bpm R=22/m BP=135/72 T=99.2 (Wt at clinic visit 3 months ago: 177

    pounds)

    General: Well appearing male

    HEENT: PERRL, EOMI, TM: clear, OP: clear, pale. No icterus

    Neck: supple, no anterior or posterior cervical lymphadenopathy

    Chest: Clear to auscultation and percussion; no wheezes, rales, or rhonchi.

    Heart: Normal S1 and S2, no murmurs, rubs, gallops

    Abdomen: Soft/nontender/nondistended. No hepatosplenomegaly.

    Rectal: Heme negative stool. No masses. Non-tender.

    Extremities: No C/C/E

Chest/Pulmonary Student Handout 2

    2. What is your initial differential diagnosis for this patient’s concerns?

Malignancy (Bronchogenic carcinoma, Leukemia)

    TB

    COPD

    Pneumonia

    Pulmonary embolism

    Bronchitis

    Aspergilloma

    Autoimmune (Goodpasture‘s syndrome, Wegener‘s granulomatosis, SLE Parasites, eg, paragonimiasis, ascariasis, hookworm, strongyloidiasis

    GI-related something (GERD, ulcer)

3. What initial tests would you order and why? (Prioritize these diagnostic tests.)

CXR => Since he may have lung cancer

    PPD => Since he may have TB

    HPD (cancer)

    Pulse Ox

    Culture (infxn)

    UA (GI issues)

    4. What is the differential diagnosis for the finding on Case 1 CXR 1 (PA view)?

See solitary pulmonary nodule in left upper lobe. Could also say ―opacification‖ in left upper lobe.

    ―Masses‖ tend to be bigger (>3 cm), so this probably isn‘t a ―mass‖. ―Nodules‖ are <3 cm.

Lung Cancer

    TB

    Pneumonia

    Collection of lymph nodes

    Fungal Infection (e.g. Aspergillosis)

    Atelctasis (rarely looks like a nodule)

    Pulmonary Hematomas

    Arteriovascular Malformation

    Hamartoma

    Histoplasmosis or any other granuloma

5. What would be your next step to evaluate the finding on the chest x-ray?

CT of chest. With contrast. (Chest CT‘s are almost ALWAYS with constrast)

    Review Case 1 CT scan 1 (Image 1A-D) and CT scan 2. (Be able to identify normal of the CT scan, including the following structures.)

    a) Heart f) Descending aorta b) Sternum g) Pulmonary vessels c) Left lung h) Liver d) Trachea i) Superior vena cava e) Arch of the aorta

Bone-Soft Tissue Window CTs

    CT 1A: See 2-3cm nodule in posterior portion of upper left lobe in pictures 4-6.

Chest/Pulmonary Student Handout 3

    CT 1B: Another mass in left lung (middle, near heart)

    CT 1C: See the mass again in 3-6.

    CT 1D:

Lung Window CT 2: See mass in 9-11 in same place as 1A.

6. What are your findings on Case 1: CT scan 1 and 2? What is the appropriate next step to

    establish a definitive diagnosis for this patient?

Dude got lung cancer

    Transbronchial Biopsy

    CT-guided transthoracic needle Biopsy

    Mediastinoscopy Biopsy

Review Case 1 CXR 2 which was taken next. What are your findings?

They‘re checking for a pneumothorax (not use of expiratory film).

7. In contrast to the patient initially reviewed in case 1, review the images of another patient--

    Images Case 1: CXR 4A-B (PA and lateral) and Case 1: CT scan 3A-B. What are the major

    findings?

CXR 3A: Hyperinflation of the lungs. Pneumothorax in top right. White things to either side are

    scapulas. Can get spontaneous, iatrogenic, or tension pneumothorax.

    CXR 3B: Hyperinflation.

CXR 4A: Nodule in left lower lobe lung near heart apex. Nodule in right middle lobe. See nodule in

    paraspinous area posterior to the heart. See central line portacath (implanted central line) -> Used for

    chemo.

    CXR 4B: See mass again

CT 3A: See 3 masses in anterior portion of right lung.

    CT 3B: See 3 masses in anterior portion of right lung.

8. What is your differential diagnosis for the finding on CXR 4?

    DDX for multiple pulmonary nodules Metastatic osteosarcoma in a teenager is what we have

    Multiple Granulomas

    Septic emboli

    Miliary TB (usually 100s of little nodules)

***Other images for Case 1 available on Blackboard will be discussed during small group sessions.

Case 2

    A 28 year old woman presents to your clinic with concerns of fatigue and swollen ‗glands‘ for the last 2 weeks. She is an established patient in your practice and she does not have any chronic medical problems.

    She reports some ‗wheezing‘ when she exercises. Her exercise tolerance has dropped notably and she

    reports difficulty keeping up with her 2 year old son. She reports night sweats on occasion and has had

    subjective fevers over the last few days. Other past medical, family and social history are negative.

    On examination, she has normal vital signs. Weight 65 kg (unchanged from her well woman exam 6

    month prior to this visit). She has shotty cervical and inguinal adenopathy. No hepatosplenomegaly is

    appreciated. Her chest is clear, and her cardiac examination is normal.

Chest/Pulmonary Student Handout 4

1. Develop a differential diagnosis.

    Cancer (lymphoma, Hodgkin‘s Disease) Pneumonia

    Acute Bronchitis

    Some sort of infection

    Exercised induced asthma

2. What tests would you order next? (include review of Image: Case 2 CXR 1A-B.)

HPD

    CXR

    Blood Cultures (if she has fever)

    Monospot

    PFT or Albuterol challenge without PFTs

CXR 1A: Marked widening of the middle and superior mediastinum.

    CXR 1B: Filling in of the retrosternal space by an ill-defined anterior mediastinal mass.

Next ? order Spiral Chest CT with contrast ? Biopsy

3. What diseases typically present as masses in a) the anterior mediastinum, b) the middle

    mediastinum and c) the posterior mediastinum?

A: T-Cell Lymphoma, Thymoma, Teratoma, Thyroid tumor

    B: Thoracic aortic aneurysms, hematomas, neoplasms, adenopathy, esophageal lesions, diaphragmatic

    hernias, and duplication cysts

    C: Neuroblastomas, neurofibromas, schwannomas, ganglioneuromas, hernias, neoplasms, hematomas, or

    extramedullary hematopoiesis.

Need to next do a CT then biopsy => She has nodular sclerosing Hodgkin‘s disease.

4. What is the next step in the evaluation of this patient?

    (Review the Image Case 2: CT scan 2A-C.) CT scan and excisional biopsy

CT 2A: Middle right does not look normal. See a mass of coalescing lymph nodes. Right paratracheal

    nodes were really big (6 cm)

    CT 2B: See some more lymph nodes and some lymph nodes around the spleen.

    CT 2C:

Case 3

A 22 year old G1P1 female presents to her family practitioner with a new onset chest pain. She reports

    sharp substernal chest pain of 1 day duration which is exacerbated by deep breaths. She is also reports intermittent mild shortness of breath. The pain is described as ―stabbing‖ and 6-7/10 on a pain scale.

    It is non-radiating. She reports one ―temperature‖ of 100 F. She also describes an occasional non-

    productive cough. She has no history of similar events or ill contacts. She had been feeling well since

    her discharge from the hospital three weeks ago following the delivery of a healthy daughter. The vaginal

    delivery was uncomplicated and she was discharged home approximately 2 days later. Pregnancy was

    uncomplicated.

Chest/Pulmonary Student Handout 5

    Past Medical Hx: Bilateral ovarian cysts removed 3 years ago. Mild asthmano treatment in last 4

    years.

    Family Hx: Father has Type II DM and HTN. Maternal grandfather died of stroke and ―clots.‖

    Social Hx: Smoked 1 pack/week before pregnancynone since. Denies drug or alcohol use. Married. Stays at home with her daughter.

    ROS: Positive for mild dyspnea on exertion. Denies nausea/vomiting/diarrhea. She feels a little down

    about being away from her daughter. Denies anxiety, guilt, difficulty with concentration, or changes in

    appetite. Sleep is variable.

    PE: Temperature: 37.0 Heart rate: 105 RR: 22 BP 110/55 Pulse oximetry 90% on room air.

    General: Awake, alert, non-toxic appearing female. Is mildly dyspneic but able to converse without

    difficulty.

    Lungs: Clear to auscultation bilaterally. No wheezes, rales, rhonchi. No dullness to percussion. Mild

    pain on palpation of the sternum.

    Heart: Normal S1 and S2. No murmurs.

    Abdomen: soft, nontender, nondistended, NABS

    Ext: no edema

    1. Develop a differential diagnosis for this patient.

Pneumonia

    Sternochondritis

    PE (she is hypercoagulable one of leading causes of peripartum mortality)

    Pericarditis

    Pneumothorax

    MI

2. How would you initially evaluate this patient and why? Prioritize your initial laboratory or

    imaging requests. (Include review of Image Case 3: CXR 1A-B (PA and lateral).)

CXR

    CT to rule out PE

    D-Dimer

    HPD

    ABG (debatable if you need this)

    Cardiac enzymes

CXR 1A: normal.

    CXR 1B: normal

3. What are the next options for imaging and the advantages and disadvantages of each?

     (Include review of Image Case 3: CT scan 1A-Bsoft tissue windows and lung windows)

CT with contrast. Could have alternatively done V/Q scan to look for PE (good if patient has contrast

    allergy or renal disease).

CT 1A: Big embolus in left main pulmonary artery. See a filling defect (contrast isn‘t there).

    CT 1B:

Risk factors for DVT

    Endothelial injury

    Turbulence

    Stasis

    Smoking + Estrogen Therapy

    Hypercoagulable states

Chest/Pulmonary Student Handout 6

    Obesity

4. Would your work-up have changed if this episode of shortness of breath occurred during the

    patient’s pregnancy?

Yes. Would have shielded the baby if you had to do a CT or could do a V/Q scan possibly. Case 4 Mild shortness of breath is common as pregnancy progresses. A 32 year old male was seen by his primary care provider for a 2-3 week history of fever (Tmax 102 F), chills, and cough productive with green sputum. He was diagnosed empirically with community acquired pneumonia and placed on Azithromycin. He did not improve after 48 hours of therapy. He presented to

    the emergency department with worsening of symptoms.

    ROS: positive for night sweats; right sided pleuritic chest pain; fatigue, malaise, and decreased

    appetite.

    PMHx: No surgeries or chronic health problems.

    Family history: unavailable.

    Social history: 6 cigarettes/day; 12 pack of beer/weekend. Originally from Honduras. Has lived in the

    U.S. for 10 years. Lives with his wife and 11 month old son.

Physical exam

    VS: T = 99, P = 86, R = 18, BP = 126/84; pulse oximetry 91% Gen: Appears comfortable at rest, no distress.

    HEENT: PERRL, EOMI, oropharynxmoist mucous membranes; no tonsillar hypertrophy or exudate Lungs: Rales in left lung field. Decreased breath sounds over left lower lung field. No wheezes.

    Heart: RRR without murmur

    Abdomen: Soft, nontender, no palpable organomegaly.

    Extremities: Without clubbing, cyanosis or edema. No calf swelling or tenderness.

1. What is your differential diagnosis?

    Pneumonia (that didn't respond to azithromycin) either resistant or viral Fungal Lung Infection

    TB ? Since from Honduras (could be latent infection)

    Aspiration Pneumonia (likes to drink)

    Bacterial URI (that didn't respond to azithromycin)

    Pleural effusion

2. What initial labs and imaging study would you order and why?

     (Include review of Image Case 4: CXR 1(PA and lateral)):

CXR => He has rales and decreased breath sound in his left lung. He has also described right sided

    pleuritic chest pain. These respiratory symptoms along with his fever point towards a lung infection of

    some sort.

    Sputum Culture => To see if anything grows.

Case 4 CXR 1A: Good inspiratory effort (I count 10 ribs on the right). Heart size looks to be within

    normal limits. Right lung looks normal with a good diaphragmatic border and a sharp costophrenic angle.

    There appears to be some infiltrate in the left lung. The diaphragmatic border isn't as sharp and the costophrenic angle appears to filled with something (meniscus sign in costophrenic angle). He has a

    possible pleural effusion. Patchy infiltrate of apex of right upper lobe. He definitely has a pneumonia.

     3. What diagnostic study would you like to perform next?

    PPD

Chest/Pulmonary Student Handout 7

    Thoracentesis

    AFB stain => for TB

    Empiric Antibiotics

    HIV Test

4. How do you determine if pleural fluid is a transudate or an exudate?

    Light's Criteria (Pleural Fluid LDH level / Serum LDH level) >0.6

    (Pleural Fluid Protein level / Serum Protein level) > 0.5

    Pleural Fluid LDH greater than 2/3 upper limit of normal serum level

5. What are common causes of transudative effusion? Common causes of exudative effusion?

(From eMedicine)

    Transudative:

     Congestive heart failure

     Cirrhosis (hepatic hydrothorax)

     Atelectasis (which may be due to malignancy or pulmonary embolism)

     Hypoalbuminemia

     Nephrotic syndrome

     Peritoneal dialysis

     Myxedema

     Constrictive pericarditis

    Exudative:

     Pneumonia

     Malignancy (carcinoma, lymphoma, mesothelioma)

     Pulmonary embolism

     Trauma

     Collagen-vascular (rheumatoid arthritis, lupus)

     Tuberculous

     Asbestos-related

     Pancreatitis

     Postcardiac injury syndrome

     Esophageal perforation

     Radiation pleuritis

     Drug-induced

     Chylothorax

     Meigs syndrome

     Sarcoidosis

     Yellow nail syndrome

Review Case 4 CXR 2A-B taken during the patient’s treatment.

Case 4 CXR 2A: Left lung appears ―less hazy‖. The left costophrenic angle still isn't really sharp, but it

    is much more normal looking than before.

Case 4 CXR 2B: Posterior costophrenic angle still looks like it might have some fluid in it.

Patient had TB.

Case 5

Review Case 5 CXR 1 and CT scan 1A-C.

What are your findings and likely diagnosis?

Chest/Pulmonary Student Handout 8

CXR 1A: Bilateral infiltrates. Bases more affected than uppers. Increased pulmonary markings

    centrally. Cardiomegaly.

    CT 1A: Diffuse alveolar infiltrates. More central than peripheral. Cardiomegaly. Huge pleural effusion on posterior right lung.

    CT 1B: same

    CT 1C: same

DDx

    CHF with Pulmonary edema

    ARDS

    Pulmonary hemorrhage

Both CXR and CT = CHF

What type of clinical presentation (i.e. symptoms, physical examination findings, and past medical

    history) might be expected for a patient with these images?

LV CHF

     Exertional dyspnea progressing to orthopnea and then dyspnea at rest ? Fatigue and exercise intolerance Paroxysmal nocturnal dyspnea Chronic nonproductive cough (often worse in recumbency) RV CHF Nocturia Anorexia

     Nausea

     Right upper quadrant pain due to chronic passive congestion of the liver and gut

    ? Tachycardia, hypotension, reduced pulse pressure, cold extremities, and diaphoresis

    ? Long-standing severe CHF: cachexia or cyanosis

Physical examination findings in LV CHF

     Crackles at lung bases, pleural effusions and basilar dullness to percussion, expiratory wheezing, and rhonchi

     Parasternal lift, an enlarged and sustained LV impulse, a diminished first heart sound

     S3 gallop

     S4 gallop in diastolic dysfunction

Physical examination findings in RV CHF

     Elevated jugular venous pressure, abnormal pulsations, such as regurgitant v waves

     Tender or nontender hepatic enlargement, heptojugular reflux, and ascites

     Peripheral pitting edema sometimes extending to the thighs and abdominal wall

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