VictoriaO Posted February 2, 2011 Share Posted February 2, 2011 Ok, here goes my d/dx: PE-always important to consider Histoplasmosis-most have nL CBC, chem, chest pain, mildly febrile, Pulmonary Actinomyces- (Does he have dental caries?) Low-grade fever, nausea, wt loss, vague abdominal discomfort Bird-Fancier's Lung (does he have pet birds or chickens?) Hypersensitivity Pneumonitis (sub-acute), anorexia, wt loss, nonspecific symptoms, looks like the CXR Nocardia-although no hemoptysis,is usually more lobar Miliary TB (although 40% typically present with HSM, lymphadenopathy) Psittacosis? Legionella PNA? though he doesn't have typical risk factors Could be Wegners Work-up: (First I'd refer to Pulm) Sputum culture peripheral blood smear Giemsa, Wright, H and E stains Gotta run, thanks again for the great case! Link to comment Share on other sites More sharing options...
eze8923 Posted February 3, 2011 Author Share Posted February 3, 2011 Sorry for the late update. Great thoughts being discussed. Here's how the CXR was read: "Markedly abnormal chest x-ray with too numerous to count pulmonary nodules of varying size, most over 1 cm. The differential diagnosis includes diffuse metastatic disease, sarcoid, infection such as fungal infection, septic emboli and lymphoma. Nonspecific, nonobstructed bowel gas pattern." So the differential that you all had was right on. I haven't seen a Wegner's case yet, but will definitely keep it in mind next time... Based on his presenting history, we went searching for malignancy and CT pan-scanned him which revealed the following: 1. Findings highly suspicious for primary esophageal malignancy with severe distal esophageal wall thickening with slight asymmetric nodularity at the upper margin of the thickening. 2. Diffuse pulmonary metastases. 3. Hepatic metastates. 4. Thoracic and upper abdominal lymphadenopathy most consistent with metastatic adenopathy. It was humbling to see the classic "cannonball" pulmonary findings. Being in the urgent care setting, we didn't go much further working this up... and perhaps the CT scan was already overkill after getting such a CXR. Nonetheless, the patient was admitted per medicine/oncology to another facility. Unfortunately, I don't have his inpatient course, so I'm assuming it went along the lines of bronchoscopy/endoscopy, PET scan, etc. The ultimate plan was for palliative chemotherapy is all that I remember, and the guy actually came back to us in urgent care in a few weeks later complaining of severe pain symptoms... Something that has stuck with me is not to let initial findings stop you from completing the w/u (if the resources are there of course). For example, if this guy didn't have pulmonary findings and had liver findings on CT, we likely would've initially started looking for a primary GI source, etc. But by involving oncology, they probably would go about finding it eventually as well. I thought one of the most unbelievable components was that he was only seen a month previously at an annual exam and deemed to have a clean bill of health for the most part... which brings me to ask about something we went on discussing about amongst the PCPs there: what are all of your thoughts on a screening CXR at 40 y/o or so? I don't know of literature or guidelines suggesting that, but I feel like in many ways it would be beneficial for future purposes... the least being able to use it as a normal comparison study and even more so in a patient population with smoking histories. Thoughts? Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Share Posted February 3, 2011 The problem with CXR as a screening tool is twofold: 1) statistically, it's not been shown to be a good screening tool (American College of Chest Physicians 2007 guidelines recommend against it) 2) without a proper diagnosis code, insurances will not pay for it. Link to comment Share on other sites More sharing options...
eze8923 Posted February 3, 2011 Author Share Posted February 3, 2011 The problem with CXR as a screening tool is twofold: 1) statistically, it's not been shown to be a good screening tool (American College of Chest Physicians 2007 guidelines recommend against it) 2) without a proper diagnosis code, insurances will not pay for it. thanks for that citation, i'll have to look those guidelines up. Link to comment Share on other sites More sharing options...
deborah212 Posted February 3, 2011 Share Posted February 3, 2011 The problem with CXR as a screening tool is twofold: 1) statistically, it's not been shown to be a good screening tool (American College of Chest Physicians 2007 guidelines recommend against it) 2) without a proper diagnosis code, insurances will not pay for it. The caveat is that current and past heavy smokers might derive benefit from low-dose spiral CT screening... http://www.cancer.gov/newscenter/pressreleases/NLSTresultsRelease Thanks for the case. Enjoyable as always. Link to comment Share on other sites More sharing options...
bradtPA Posted February 3, 2011 Share Posted February 3, 2011 Agreed, although the Mayo study showed no improvement in mortality from CT as a screening tool. Lung cancer just is a tough disease to beat. I have diagnosed two cases in the last year, and both patients lasted less than six months.... http://www.mayoclinicproceedings.com/content/82/1/14.full Link to comment Share on other sites More sharing options...
deborah212 Posted February 3, 2011 Share Posted February 3, 2011 That is rough, Brad. I don't think I could ever transition to oncology precisely for that reason. Link to comment Share on other sites More sharing options...
marilynpac Posted February 3, 2011 Share Posted February 3, 2011 Yes, there are so many cancers that by the time the patient feels symptomatic....it's almost too late. I just lost a beloved cousin last week to ovarian ca. By the time she was symptomatic(sob), she was already in stage 4..... Link to comment Share on other sites More sharing options...
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