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