Lung—physical findings-Pleural effusions-pneumothorakas-pneumonia- apostima pneumona-mesothilioma-pancoast- Superior vena cava syndrome - karkinoi Flashcards
A patient has dyspnea, decreased right breath sounds, dullness to percussion, and decreased tactile fremitus. What is the likely diagnosis?
Pleural effusion
A patient has crackles on the right with dullness to percussion and no tactile fremitus. Would there be tracheal deviation?
Yes, as there will be deviation away from the side of the lesion if the effusion is large (this is a pleural effusion on the right)
A patient has decreased breath sounds on the right, dullness to percussion, and tracheal deviation to the right. What does he have?
Atelectasis (bronchial obstruction) on the right
What are the physical exam findings in a patient with atelectasis (bronchial obstruction)?
Decreased breath sounds, dullness to percussion, decreased fremitus, tracheal deviation toward the side of the lesion
A patient has dyspnea, hyperresonance, decreased breath sounds on the left, and tactile fremitus. Is there tracheal deviation?
There is no tracheal deviation (this patient has a simple pneumothorax)
A man has dyspnea, absent right breath sounds, hyperresonance, and tracheal deviation to the left. How will fremitus be affected?
Fremitus will decrease (this patient has a tension pneumothorax)
A patient has fever, dyspnea, right bronchial breath sounds, dullness to percussion, and increased tactile fremitus. Likely diagnosis?
Lobar pneumonia
A patient has shortness of breath, severe HF, bronchial breath sounds, dullness to percussion at bases, and increased fremitus. Diagnosis?
Pulmonary edema
A patient has fever, bronchial breath sounds, dullness to percussion, and increased fremitus. Is there tracheal deviation?
No tracheal deviation, as with pulmonary edema and simple pneumothorax (this patient has lobar pneumonia)
Pleural effusion and tension pneumothorax have tracheal deviation ____ (away from/toward) the side of the lesion.
Away from
Atelectasis (from bronchial obstruction) has tracheal deviation ____ (away from/toward) the side of the lesion.
Toward
In terms of pleural effusions, transudates have ____ (less/more) protein than exudates.
Less
Name the three types of pleural effusions.
Transudative, exudative, and lymphatic
Transudative pleural effusion is caused by ____ (increased/decreased) hydrostatic pressure or ____ (increased/decreased) oncotic pressure.
Increased, decreased
Name four causes of exudative pulmonary effusions.
Malignancy, pneumonia, collagen vascular disease, and states of increased vascular permeability (trauma)
What makes an exudate cloudy?
Exudates are cloudy because of their higher protein content
A patient develops a pleural effusion secondary to trauma. Is this more likely to be transudative or exudative?
Exudative (trauma is a state of increased vascular permeability)
A patient with an exudative pleural effusion requires immediate drainage of the effusion. Why is this the case?
Exudates have a high infection risk
A woman has a pleural effusion that consists of high triglyceride levels and has a milky appearance grossly. What type of effusion is this?
Lymphatic
What causes lymphatic effusions (chylothorax)?
Thoracic duct injury from trauma or malignancy
Name four types of pneumothorax.
Primary spontaneous, secondary spontaneous, traumatic, and tension
A tall young man has unilateral chest pain, dyspnea, and ruptured apical blebs. Which way is his trachea deviated?
Toward the affected lung (this is a spontaneous pneumothorax)
A tall, thin 15-y/o male has chest pain and dyspnea. There is decreased fremitus and hyperresonance on the left chest. What caused this?
Primary spontaneous pneumothorax occurs in tall, thin, young males as a result of apical bleb or cyst rupture
Name two causes of secondary spontaneous pneumothorax
Lung disease (e.g., emphysema, infections) and barotrauma from high pressures on use of mechanical ventilation
A patient is on mechanical ventilation. He then complains of unilateral chest pain and dyspnea. What happened?
He likely developed a pneumothorax from the high pressure of mechanical ventilation
A man presents after falling from the top of a roof. He has chest pain, dyspnea, diminished breath sounds, and tactile fremitus. Diagnosis?
This is likely a traumatic pneumothorax from blunt trauma, also seen in penetrating trauma (e.g., gunshot wounds)
A patient is involved in a motor vehicle crash and has a right-sided tension pneumothorax. Which direction is the trachea pointing?
Left (a tension pneumothorax deviates the trachea away from the affected lung)
List three bacterial causes of interstitial pneumonia.
Mycoplasma, Legionella, and Chlamydia
Which type of pneumonia is most often caused by viruses?
Interstitial (atypical) pneumonia
List four viruses that commonly cause interstitial pneumonia.
Respiratory syncytial virus, influenza virus, cytomegalovirus, and adenovirus
Interstitial pneumonia characteristically shows diffuse, patchy inflammation that is localized to what areas of the lung?
Interstitial areas at the alveolar walls
The distribution of interstitial pneumonia characteristically involves how many lobes?
At least one, usually more
Which category of pneumonia typically has a less acute presentation?
Interstitial pneumonia (walking pneumonia)
What is a lung abscess?
A localized collection of pus within the lung parenchyma
Name two conditions that can predispose a patient to lung abscess formation.
Bronchial obstruction (e.g., tumor) or oropharyngeal content aspiration (e.g., loss of consciousness during seizures or heavy alcohol use)
What finding on chest x-ray is suggestive of a lung abscess?
Air-fluid levels
A roofer who smokes is noted to have hemorrhagic pleural effusions and pleural thickening. Is his smoking to blame?
Not likely, as this is mesothelioma secondary to asbestosis, for which smoking is not a risk factor
A roofer is noted to have pleural thickening and a biopsy of the lesion is performed. What would it show on histology?
Psammoma bodies on histology (this patient has mesothelioma)
A plumber has chest pain and dyspnea. Histology shows psammoma bodies. What kind of pleural effusion is associated with his condition?
Pleural effusion is exudative (this patient has mesothelioma from asbestos exposure)
CT scan of the chest in a patient with dyspnea shows an apical lung mass. What neurologic structures are at risk of being compressed?
The cervical sympathetic plexus (this is a Pancoast tumor)
When Pancoast tumor disrupts the cervical sympathetic plexus, it can result in what condition? What findings will be seen?
Horner syndrome; one sees ipsilateral ptosis, miosis, and anhidrosis
A patient has cough, weight loss, and malaise. Exam shows ipsilateral eyelid droop, miosis, and no sweating. What does chest X-ray show?
Given the history, CXR will likely show an apical opacity characteristic of a Pancoast tumor
A man is diagnosed with a Pancoast tumor. Other than Horner syndrome, what other findings may you find?
Sensorimotor deficits, hoarseness, and/or obstruction of the superior vena cava leading to SVC syndrome
Superior vena cava syndrome is most likely caused by what?
Neoplasms and thromboses from indwelling catheters
A patient with superior vena cava syndrome is rushed to the ED by his doctor. Why does the doctor consider this a major emergency?
If obstruction is severe, elevated cranial pressure may increase the risk of aneurysm formation or rupture of intracranial arteries
Superior vena cava syndrome puts a patient at risk of rupture of what arteries?
Intracranial arteries, as a result of increased intracranial pressure
A man with a left lung mass has headaches and dizziness. Brain angiography shows a berry aneurysm. What major vessel is blocked by the mass?
The superior vena cava (this is SVC syndrome)
What type of cancer is the leading cause of cancer death?
Lung cancer
A patient with a history of smoking has a cough and hemoptysis. Exam shows decreased breath sounds and wheezing. What do you suspect?
Lung cancer (a common clinical presentation is cough, bronchial obstruction, hemoptysis, and wheezing)
• What are common presenting radiologic findings in lung cancer patients?
Pneumonic coin lesions on chest X-ray, noncalcified nodules on CT
Name four common sites of metastases from primary lung cancer.
Brain, bone, liver, and adrenals
In association with a primary lung cancer, what finding suggests bone metastases?
Pathologic fractures
A patient is diagnosed with the leading cause of cancer death. What two findings on physical exam might suggest liver metastases?
Jaundice and hepatomegaly (this is likely lung cancer, the leading cause of cancer death)
Metastases occur ____ (more/less) frequently than primary neoplasms when it comes to lung cancer.
More
A patient is found to have multiple pulmonary tumors. If these are metastatic, name the most common sites they would have originated from.
Breast, colon, prostate, bladder
What are the common complications of lung cancer?
SVC syndrome, Pancoast tumor, Horner syndrome, Endocrine (paraneoplasia), Recurrent laryngeal nerve symptoms, Effusions (SPHERE)
A patient with lung cancer experiences unexpected voice changes. How is it changing, and why might this be happening?
It can become hoarse, due to compression of the recurrent laryngeal nerve
Which potential spaces can develop effusions as a result of lung cancer?
Pleural and pericardial spaces
List two forms of bronchogenic carcinoma that tend to arise peripherally in the lungs.
Adenocarcinoma and large cell carcinoma
List risk factors that lead to lung cancer.
Asbestos exposure, family history, radon, smoking, secondhand smoke
A patient is diagnosed with an oat cell carcinoma of the lung. In which area of the lungs does this cancer type typically arise?
Centrally (small cell [oat cell] cancer is a very aggressive type of lung cancer)
Name three possible products of neoplastic neuroendocrine cells in small cell carcinoma.
ACTH, SIADH, and Antibodies against presynaptic calcium channels or neurons
An elderly smoker with hemoptysis and known lung cancer develops muscle weakness that improves with activity. What is the diagnosis?
Lambert-Eaton syndrome (a paraneoplastic syndrome associated with small cell carcinoma of the lung)
What is the treatment of small cell lung cancer?
This inoperable cancer is treated with chemotherapy
A smoker is newly diagnosed with lung cancer, which has myc amplification, and chromogranin A positivity on histology. Treatment?
Treat with chemotherapy, as it is usually inoperable (this patient has small cell [oat cell] cancer)
Name the non-small cell lung cancers.
Adenocarcinoma, squamous cell carcinoma, large cell carcinoma, bronchial carcinoid tumor
A patient is diagnosed with lung cancer that is the most common nonsmoker subtype. In which area of the lungs does this typically arise?
Peripherally (this is adenocarcinoma of the lung)
What is the most common type of lung cancer in nonsmokers and women?
Adenocarcinoma
Adenocarcinoma has mutations in the ____ oncogenes. Small cell carcinoma has mutations in ____ oncogenes.
KRAS, EGFR, ALK; myc
What lung cancer is associated with hypertrophic osteoarthropathy?
Adenocarcinoma
A nonsmoker has cough, clubbing, and joint pain. Chest x-ray shows hazy infiltrates, suggesting cancer. Where is growth most likely to be?
Along alveolar septa giving an appearance of wall thickening (the patient has bronchoalveolar cancer [excellent prognosis])
Bronchioloalveolar adenocarcinoma can present similarly to what other noncancerous pathological lung disease?
Pneumonia
A woman has chest pain, dyspnea, and hemoptysis. Histology shows a glandular pattern and mucin (image). Did this woman smoke?
Unlikely, as this is adenocarcinoma, which classically arises in nonsmokers and women
A patient is diagnosed with a squamous cell carcinoma of the lung. In which area of the lungs does this cancer type typically arise?
Centrally
A patient with lung cancer has elevated calcium. Is the causative malignancy typically found centrally or peripherally?
Centrally, as this is squamous cell cancer, with release of parathyroid hormone–related peptide causing hypercalcemia
What are the 3Cs of squamous cell carcinoma?
Cavitation, Cigarettes, and hypercalcemia (from parathyroid hormone–related protein)
A patient is diagnosed with a large cell carcinoma of the lung. In which area of the lungs does this cancer type typically arise?
Peripherally
What peripherally arising form of bronchogenic carcinoma is most anaplastic or undifferentiated?
Large cell carcinoma, which has a poor prognosis
What is the usual approach to the treatment of large cell carcinoma of the lung?
Surgical removal (it is poorly responsive to chemotherapy)
A patient with a lung mass has a biopsy showing pleomorphic giant cells that can secrete β-hCG. What cancer type is this?
Large cell carcinoma
What two types of lung cancer have excellent prognoses?
Bronchial carcinoid and the bronchioloalveolar subtype of adenocarcinoma
What are the classic symptoms of carcinoid syndrome? What is the cause?
Flushing, diarrhea, wheezing; the symptoms are caused by serotonin secretion into the bloodstream
A patient with dyspnea, chest pain, and chronic cough now has flushing, diarrhea, and wheezing. What do you expect biopsy to show?
Nests of neuroendocrine cells that are chromogranin A positive (this is a bronchial carcinoid tumor)
