Transcript Morning Report 10-28-16

Morning Report
10/26/16
Annie Belzwoski, MD
PGY2
60 y/o Female w/ body
aches, and cough
Morning report 10/26/16
In the Emergency Room…

Initial VS: 37.2, 93, 108/68, 20, 92% RA

Gen: thin, frail, elderly woman, lying very still in bed. calm, pleasant.
HEENT: No conjunctival injection or scleral icterus. Conjunctival pallor. PERRLA,
EOMI. No frontal or maxillary tenderness. No OP erythema. No cervical LAD.
Neck: Flat JVD, no thyromegaly
Chest: RRR. 3/6 systolic murmur best heard oat RUSB, no radiation to carotids.
Lungs: CTAB, no wheezes or crackles
Abd: +BS, soft, nd, nt, no organomegaly
Ext: 2+ radial, dp, pt, pulses b/l. No edema
No rheumatoid nodules in elbows. Ulnar deviation in hands bilaterally. MCPs, PIPs,
DIPs notender to palpation.
Neuro: No sensory or motor deficits. Toes downgoing bilaterally
Initial Labs

JUL 28 15:27
L 133 | L 96 | 9 /
_____________________ 85
5.0 | 29 | 0.53 \
\ L 7.6 /
H 24.9 _______ H 956
/ L 24.8 \
ESR 98
CRP 259.5
Lipase 17
Lactate 1.1
UA neg
Alk Phos 172
Alb 2.0
Imaging
CXR

7/28/16 XR Chest
No definite acute cardiopulmonary process. If clinical suspicion for pneumonia
is high, recommend follow-up two view chest radiograph and/or treatment
based on symptomatology.
Scattered calcified and noncalcified pulmonary nodules as well as a focal left
hemithoracic pleural thickening are nonspecific but can be seen with
sequelae of old granulomatous disease.
CT Chest Abdomen w/Contrast
IMPRESSION:

Large right lower lobe lung abscess measuring up to 8.4 cm with surrounding right lower lobe
consolidation, additional micro microabscesses, mucus plugging and broncholiths. Rightsided pleural effusion appears transudative. Underlying pulmonary tuberculosis cannot be
excluded. Alternatively, the possibility of a large pulmonary neoplasm cannot entirely be
excluded. Recommend correlation with cytology if pulmonary abscess is drained.

Centrilobular nodularity in the left lung is nonspecific but may represent endobronchial
spread of infection

Enlarged necrotic hilar and mediastinal lymph nodes, likely secondary to pulmonary infection,
less likely secondary to malignancy.

No CT evidence for mastectomy. Consider correlation with clinical history.
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Right thyroid lobe nodule.
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Nonspecific cystic lesions in the spleen. They do not have the appearance of micro abscess
sees. Differential considerations include focal splenic abscesses versus splenic cysts.
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7.4 cm left adnexal cyst. Given the patient's age gynecology consultation is suggested if
indicated.
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Evidence of old granulomatous disease in the lungs, hila and liver.
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Osteopenia and multiple probable vertebral body hemangiomas.

Nonspecific gallbladder wall thickening. Clinical correlation for acute cholecystitis.
ECHO
ECHO
Summary:
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1. Left ventricle: Systolic function is normal. The estimated ejection fraction is
65-70%. Features are consistent with a pseudonormal left ventricular filling
pattern, with concomitant abnormal relaxation and increased filling pressure
(grade 2 diastolic dysfunction).

2. Pericardium, extracardiac: A small pericardial effusion is identified. There is no
evidence of cardiac tamponade.

3. Large left pleural effusion.

4. Right atrial pressure is estimated at 3 mmHg and Pulmonary pressures are
estimated to be 31mmHg.

5. To the extent visualized there is no evidence of valvular vegetations.
Recommend TEE if clinically indicated.
Micro
Crypto neg
Aspergilllus Neg
Cocci neg
Echinococcus Neg
Resp Cx Gram Stain
Few Gram Positive Cocci
Few White Blood Cells
Rare epithelial cells
Brucella Ab Neg
AFB neg x3
MTB-PCR neg x2
PCP DFA neg
Blood cultures Neg x 4 dayts
Resp Cx Gram Stain
Rare White Blood Cells
Few epithelial cells
Few Gram Positive Cocci
Rare Gram Positive Rods
Rare Gram Negative Rods
MRSA neg
Resp Culture
Neg Acid Fast, fungal cultures
Bronchoscopy
Normal mucosia and patent airways on the left. Right upper
lobe with normal mucosa and airways. RML airway with small amount of
airway compression. RLL airway completely compressed with abnormal
moderately noduler mucosa, see images. RLL superior segment with
moderate airway compression but BAL performed in this segment
Pathology
Right lower lobe of lung (endobronchial biopsy):
- Invasive keratinizing squamous cell carcinoma, moderately differentiated.
- Immunostains: CK5/6- positive; p63- positive; TTF-1- negative (pattern supports
the above diagnosis)
Bronchoalveolar lavage, RLL (cytology):
- Rare atypical squamous cells
- Alveolar macrophages, some pigmented in the background of mixed
inflammatory cells
Lung Cancer
Annie Belzowski
Scope

In 2012, 1.8 million people were diagnosed with lung cancer and 1.6 million
people died of the disease (1)

According to the ACS, in 2016 there were 224,390 new cases and 158,080
deaths in the United States (2)
Subtypes
Less common types of lung cancer include pleomorphic, carcinoid tumor, salivary
gland carcinoma, and unclassified carcinoma
Wistuba I, Brambilla E, Noguchi M. Chapter 17: Classic Anatomic Pathology and Lung Cancer. In: Pass HI, Ball D, Scagliotti GV, eds. The IASLC
Multidisciplinary Approach to Thoracic Oncology. Aurora, CO: IASLC Press; 2014:217-240. via https://www.lungevity.org/about-lung-cancer/lungcancer-101/types-of-lung-cancer
Risk Factors

Smoking: Accounts for 90% of all Lung cancers

Radiation Therapy: Hodkins and breask cancer

Environmental Toxins: second hand smoke, asbestos, radon and metas
(Arsenic, chromium and nickel), ionizing radiation and polycyclic aromtc
hydrocarbons

Pulmonary Fibrosis

HIV Infection

Genetic factors

Alcohol

Dietary factors
3
A Note about Screening

CXR and sputum cytology DO NOT reduce mortality from lung cancer

National Lung Screening Trial compared CT screening with Chest XRAY

20% decrease in lung CA mortality in heavy smokers who were screening
annually for three years and is only trial to show benefit in mortality
reduction

USPSTF low dose CT scanning a B recommendation for those with high risk

CMS requirements
3

55-77 years of age

No symptoms of lung cancer

30 pack year smoking history

If they have quit have done so within 15 years
Clinical
Manifestations
Local effects
Spread
Paraneoplastic
syndromes
Local Effects
Cough (45-74%)
Hemoptysis (27-29%)
Chest pain (27-49%)
Dyspnea (37-58%)
Hoarseness (8-18%)
Pleural Involvement
Superior Vena Cava Syndrome
Pancoast Syndrome
3, 4
Extrathorasic Metastasis
Liver
Adrenal Glands
Bones
Brain
Paraneoplastic syndromes
Hypercalcemia
SIADH
Neurologic
Hematological manifestations
Hypertrophic Osteoarthropathy
Dermatomyositis and Polymyositis
Crushing Syndromes
Staging
5, 6
Bone Scan

IMPRESSION:
1. Multiple foci of moderate uptake within the bilateral ribs are suspicious for
osseous metastases.
2. Focal increased uptake within the right posterior 4th and 5th ribs and right
inferolateral ribs in a vertical alignment may be related to prior trauma.
Evaluation
NSCLC: non-small cell lung cancer; RT: radiation therapy; SBRT: stereotactic body radiation therapy.
* Based upon comorbidities, age, or refusal of surgery.
¶ SBRT preferred for tumors <5 cm; definitive RT with conventional fractionation for larger lesions.
Δ Primarily for tumors >4 cm; observation is an alternative.
◊ Consultation with medical oncology, radiation oncology, and thoracic surgery indicated prior to definitive therapy. Concurrent
chemoradiotherapy, surgery, or induction therapy followed by resection in carefully selected patients. 7
Prognosis
Overall survival by TNM grouping, non-small cell lung cancer
7
Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming
(seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2007; 2:706. Copyright © 2007 Lippincott Williams & Wilkins.
Graphic 73088 Version 14.0
References
1.
Brambilla E, Travis WD. Lung cancer. In: World Cancer Report, Stewart BW,
Wild CP (Eds), World Health Organization, Lyon 2014.
2.
“Cancer Statistics” CA Cancer J Clin. 2016 Jan-Feb;66(1):7-30. doi:
10.3322/caac.21332. Epub 2016 Jan 7.
3.
Midthun D , Lilenbaum, R, Vora,S “Overview of the risk factors, pathology,
and clinical manifestations of lung cancer”, PubMed, Feb, 2015
4.
Hyde, L, Hyde, Symptoms of lung cancer in over 3500 patients at
presentation CI. Chest 1974; 65:299-306 and Chute CG, et al. Cancer 1985;
56:2107-2111. Graphic 76229 Version 1.0
5.
Nasser, “The Best Oncologist”
http://www.thebestoncologist.com/Cancer_Diseases/Lung_Cancer/Staging_of
_Lung_Cancer.html 2010
6.
Thomas, K, Gould M, “Overview of the initial evaluation, diagnosis, and
staging of patients with suspected lung cancer” Pub Med, July 2016
7.
West, H, Vallieres, E, Schlid, S “Management of stage I and stage II non-small
cell lung cancer”, PubMed, Oct 2016