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Differential Diagnoses
Differential DiagnosesDifferential Diagnosis Rule In Rule Out
Lymphoma Enlarging cervical mass and axillary lymph node, exposure to benzene (tricycle driving & smoking), wt loss
Cannot be ruled out
TB Cough, wt loss, exposure to TB (father & sister)
Cannot be ruled out
Laryngeal CA (w/ lymphatic spread)
Enlarging cervical mass, cough, hoarseness, difficulty swallowing, wt loss, smoking history
Cannot be ruled out
Differential DiagnosesDifferential Diagnosis Rule In Rule Out
Esophageal CA (w/ lymphatic spread)
Enlarging cervical mass, difficulty swallowing, cough, wt loss, smoking history
Cannot be ruled out
Cancer of the Throat (w/ lymphatic spread)
Enlarging cervical mass, hoarseness, difficulty swallowing, cough, wt loss, smoking history
Cannot be ruled out
Lung CA (w/ lymphatic spread)
Cough, hoarseness, wt loss, shoulder pain, difficulty swallowing, smoking history, enlarging cervical mass
Cannot be ruled out
Differential DiagnosesDifferential Diagnosis Rule In Rule Out
Pancoast tumor (w/ lymphatic spread)
Shoulder pain, wt. loss Cannot be ruled out
Superior Vena Cava Syndrome
Facial edema, hoarseness, cough, enlarging neck mass
Cannot be ruled out
Pneumonia Occasional productive cough
No other associated signs and symptoms (fever, chills, fatigue, malaise, headache, chest pain
Diagnostics
HEMATOLOGYLaboratory Work-Up
Normal June 23, 2010 Remarks
WBC 4-11 x 10 9/L 8.08 x 10 9/L NORMAL
RBC 4-6 x 10 9/L 4.82 x 10 9/L NORMAL
Hgb 120-180g/L 142g/L NORMAL
Hct 0.370-0.540% 0.431% NORMAL
MCV 80-100fL 89.4fL NORMAL
MCH 27-31pg 29.5pg NORMAL
MCHC 320-360g/L 329g/L NORMAL
RDW-CV 150-450 x 10 9/L 129 x 10 9/L REDUCED
Platelets 2-4 x 10 11/L 3.1 x 10 11/L NORMAL
Neutrophil 0.5-0.7 0.764 SLIGHTLY ELEVATED
Lymphocytes 0.2-0.5 0.103 REDUCED
Monocyte 0.02-0.09 0.082 NORMAL
Eosinophil 0.0-0.06 0.047 NORMAL
Basophil 0.0-0.02 0.004 NORMAL
APTT 36.4 36.3 NORMAL
PT 12-15 seconds 12.5 seconds NORMAL
BLOOD CHEMISTRYLaboratory Work-Up
Normal June 23, 2010 Remarks
BUN 3.2-8.0 mmol/L 2.46 REDUCED
Creatinine 53.133 umol/L 71 ELEVATED
Sodium 135-145 mmol/L 137 NORMAL
Potassium 4.0-4.5 mmol/L 4.3 NORMAL
Calcium 2.12-2.75 mmol/L 2.41 NORMAL
Albumin 38-51 g/L 31 REDUCED
AST 0-34 U/L 50 ELEVATED
ALT 0-30 U/L 42 ELEVATED
Total Bilirubin 0-17.1 umol/L 5.90 NORMAL
Dir Bilirubin 0-3.42 umol/L 1.96 NORMAL
Ind Bilirubin 3.4-13.7 umol/L 3.94 NORMAL
Urate 0.13-0.44 mmol/L 0.31 NORMAL
URINALYSISLaboratory Work-Up
Normal June 23, 2010 Remarks
Color Yellow Light Yellow NORMAL
Transparency Clear Clear NORMAL
SG 1.016-1.022 1.025 NORMAL
Ph 4.6-6.5 6.0 NORMAL
Sugar (-) (-) NORMAL
Albumin (-) (-) NORMAL
RBC 0-2/hpf 4/hpf MICROSCOPIC HEMATURIA
WBC 0-5/hpf 2/hpf NORMAL
Casts 3/hpf
Bacteria (-) 1/hpf POSSIBLE INFECTION
Ketones (-) +1 KETONURIA
Differential DiagnosesDifferential Diagnosis
Rule In Rule Out
Pneumonia Occasional productive cough
No other associated signs and symtoms; no sign of infection based on hematology
Liver CA Reduced liver function
Cannot be ruled out
Liver damage Reduced liver function
Cannot be ruled out
Ketoacidosis Ketones in the urine, reduced food intake, wt loss
Cannot be ruled out
CHEST X-RAYImaging Studies
MULTIPLE CONTIGUOUS AXIAL CT SCAN OF THE CHEST WITH IV CONTRAST
Imaging Studies
Imaging Results• Well defined lobulated pulmonary mass with
irregular margin with eccentric calcifications at the superior basal segment of the left lower lobe
• <1cm pulmonary nodule at the posterior basal segment of the right lower lobe
• With either linear fibrosis or subsegmental atelectasis at the anterobasal segment of the left lower lobe
• Pleural thickening, left lung• Thoracic spondylosis• No liver metastasis
SURGICAL PATHOLOGYTissue Diagnosis
April 26, 2010
Malignant columnar cells forming a papilloid pattern, with large nuclei and scanty cytoplasm, suggestive of metastatic poorly undifferentiated adenocarcinoma
SCLC vs. NSCLCSCLC NSCLC
Scant cytoplasm Abundant cytoplasm
Hyperchromatic nuclei w/ fine chromatin pattern
Pleomorphic nuclei w/ coarse chromatin pattern
Indistinct nucleoli Prominent nucleoli
Diffuse sheet of cells Glandular or squamous architechture
AFB SPUTUMCulture
June 26, 2010
• Day 1: (-) AFB• Day 2: (-) AFB• Day 3: (-) AFB
Diagnosis
Working Diagnosis
Lung cancer, non-small cell (adenocarcinoma), stage 4, currently undergoing cobalt radiotherapy with possible malnutrition and pulmonary TB. To consider kidney and liver damage.
Pain when swallowing
Decreased food intake
Guconeogenesis
Muscle wasting
Hypoalbuminemia
Elevated AST, ALP
Ketone body production
• http://www.hrpca.org/Bookletch19.htm• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626451/• http://www.hrpca.org/Bookletch19.htm• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626451/• http://www.chemocare.com/managing/hypoalbuminemia-low-albumin.asp• http://www.medicinenet.com/esophageal_cancer/page3.htm#4whatare• http://www.cancer.gov/cancertopics/factsheet/sites-types/head-and-neck#5• http://www.medicinenet.com/lung_cancer/page4.htm#toce• http://www.emedicinehealth.com/pancoast_tumor/page3_em.htm#Pancoast Tum
or Symptoms
• http://emedicine.medscape.com/article/760301-overview• http://www.medicinenet.com/superior_vena_cava_syndrome/page2.htm#tocd• http://emedicine.medscape.com/article/177354-overview• HPIM 17th edition