Hemoptysis Case 2

A fifty-year-old man presents to his primary care doctor complaining of chronic cough with hemoptysis, weakness, frequent urination, thirst, and a decreased ability to concentrate. Review of systems reveals fever, chills, night sweats, and a twenty-pound weight loss. He has a
seventy pack-year smoking history. On examination, his lungs are clear to auscultation, but neurologic examination reveals global hyporeflexia.
A chest x-ray film reveals a 4-cm hilar non-cavitary opacity in the left lung. Serum electrolytes show K+ = 2.3 mEq/L. Calcium is within normal limits.

Q 1
Which of the following is the most likely diagnosis?
/ A. Adenocarcinoma
/ B. Bronchioloalveolar carcinoma
/ C. Mesothelioma
/ D. Small cell carcinoma
/ E. Squamous cell carcinoma

Q 2
Which of the following substances secreted from the lesion is the most likely cause of this patient's electrolyte disturbance?
/ A. ACTH
/ B. Aldosterone
/ C. Angiotensin ll
/ D. Epinephrine
/ E. PTH

Q 3
As the patient's condition progresses, the patient grows increasingly hoarse. Which of the following is the most likely reason for the patient's hoarseness?
/ A. Enlargement of the mass has severely decreased inspiratory volume.
/ B. Extension of the mass into the larynx
/ C. Impingement on cranial nerve XII
/ D. Impingement on the recurrent laryngeal nerve
/ E. Metastasis into the speech centers of the brain

Q 4
This patient is given cisplatin as part of his chemotherapeutic regimen. Which of the following is a known adverse effect of cisplatin?
/ A. Cardiotoxicity
/ B. Hemorrhagic cystitis
/ C. Nephrotoxicity
/ D. Profound myelosuppression
/ E. Pulmonary fibrosis

Q 5
In addition, this patient is given etoposide. Which of the following best describes the mechanism of action of etoposide?
/ A. Etoposide cross-Iinks DNA
/ B. Etoposide induces single- and double-stranded breaks in DNA
/ C. Etoposide inhibits dihydrofolate reductase
/ D. Etoposide inhibits microtubule formation
/ E. Etoposide inhibits topoisomerase ll

Q 6
The patient has been aware of his diagnosis and prognosis for several weeks now. He makes the statement "I had successes and failures but I'm pretty sure l got as much living out of the last 50 years as anybody could." This statement suggests that the patient is experiencing which of the following of Erikson's stages?
/ A. Ego integrity vs. despair
/ B. Generativity vs. self absorption
/ C. Identity vs. role confusion
/ D. Industry vs. inferiority
/ E. Intimacy vs. isolation

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Hemoptysis Case 2 Answers
A1
The correct answer is D. This patient has classic findings for small cell carcinoma of the lung (also known as oat cell carcinoma). Patients with small cell carcinoma typically present with constitutional symptoms, cough, and hemoptysis. Paraneoplastic syndromes are common with this cancer, and may often be the first symptoms to present. This patient has hypokalemia and many of the symptoms that accompany it: muscular weakness, frequent urination, thirst, and decreased ability to concentrate. This patient's radiographic findings (non-cavitary hilar mass) also support the diagnosis of small cell carcinoma.
Adenocarcinomas (choice A) tend to present as peripheral masses, and paraneoplastic syndromes are rare.
Bronchioloalveolar carcinoma (choice B) is a subtype of adenocarcinoma. It arises from the peripheral airways, and while it can present as a discrete mass, it typically is indistinct radiographically as it grows down the airway surfaces. Again, paraneoplastic syndromes are rare.
Mesothelioma (choice C) is a pleural malignancy associated with asbestos exposure. They do not present as hilar masses. 50% metastasize, but death usually results from local extension. They tend to produce large effusions that may obscure the mass on chest x-ray films.
Squamous cell carcinoma (choice E), like small cell carcinoma, has a strong association with smoking. These tumors may present in a similar fashion, with a more central lung lesion, but paraneoplastic syndromes with squamous cell carcinoma tend to be related to the secretion of a PTH-like substance, resulting in hypercalcemia. Thus the diagnosis of small cell carcinoma is more likely.

A2
The correct answer is A. ACTH is often secreted by small cell lung carcinoma. The clinical results are those seen from uninhibited ACTH secretion: the adrenal gland increases the production of glucocorticoids and mineralocorticoids. Thus, patients experience hypokalemia, hyperglycemia, and hypertension. The chronic sequelae of this process (Cushingoid symptoms) are not usually seen, due to the metabolic demands of the neoplasm and the short survival of affected individuals.
None of the other hormones listed above are commonly secreted by small cell cancers.

A3
The correct answer is D. As seen with many hilar masses, impingement on the recurrent laryngeal nerve produces hoarseness. The recurrent laryngeal nerve courses inferiorly to the aortic arch and then turns superiorly to innervate the intrinsic muscles of the larynx (except the cricothyroid muscle). When this nerve sustains unilateral damage, hoarseness results, as patients have difficulty abducting the vocal cords. Bilateral damage results in acute breathlessness, because both of the vocal cords move to the midline and block the airway.
Enlargement of the mass (choice A) to a size that would affect speech would likely produce pulmonary collapse, not hoarseness.
Extension of the mass from the hilum of the lung to the larynx (choice B) would be unlikely. Many critical structures are in this course, and the patient would likely not survive long enough to become hoarse from direct extension.
Impingement on cranial nerve XII (choice C) would affect movement of the tongue. Not only would metastasis or direct extension to the anatomic site of this nerve be unlikely, this event would not make a patient hoarse.
Metastasis to the speech centers (choice E) would produce more profound speech difficulties. The characteristics of the aphasia would depend upon which speech center is affected ( i.e., fluent vs. expressive aphasia).

A4
The correct answer is C. Cisplatin is a heavy metal compound used in the treatment of small cell carcinoma of the lung. Cisplatin cross-links DNA, though it is not a true alkylating agent. The dominant adverse effect seen with its administration is nephrotoxicity, as it is toxic to both proximal and distal renal tubule epithelium. It produces only modest myelosuppression.
Doxorubicin causes cardiotoxicity (choice A) and congestive heart failure may result.
Cyclophosphamide is a chemotherapeutic agent known to cause hemorrhagic cystitis (choice B).
The myelosuppression with cisplatin is modest. Many other chemotherapeutic agents are known to severely suppress the marrow (choice D).
Bleomycin is known to cause pulmonary fibrosis (choice E).

A5
The correct answer is E. Etoposide acts by inhibiting the enzyme topoisomerase II. Topoisomerases are enzymes that create and repair breaks in DNA during replication. This enzyme is needed to relieve topologic and conformational changes as the DNA is "unzipped" during replication and transcription.
Alkylating agents, such as cyclophosphamide, cross-link DNA (choice A).
The antitumor antibiotics, such as bleomycin, act by inducing breaks in DNA (choice B).
Methotrexate is an antimetabolite chemotherapeutic agent that inhibits dihydrofolate reductase (choice C), an enzyme needed to produce purine nucleotides. Thus the "purine shortage" produced hinders cell replication.
The Vinca alkaloids exert their effects by inhibiting microtubule formation (choice D). Without microtubules, cells cannot mobilize their chromosomes, and thus mitosis is inhibited.

A6
The correct answer is A. In the ego integrity vs. despair stage, individuals reconcile their achievements and failures and face the fact that any human life is limited. Persons completing this task find self-worth in reviewing their life events. Persons stuck at this task cannot admit that time has run out.
Generativity vs. self-absorption (choice B) usually occurs from age 30-65. It involves noting ones contributions as a parent (in the broadest sense) and eventually "passing the torch" to the next generation. Persons stuck in this phase refuse to give up any power to their successors, and maintain ultimate authority without making a place for the next generation.
Identity vs. role confusion (choice C) occurs during adolescence, and is usually defined by emotional and or geographic separation from the actual parents, with an internal identity based on both similarities and differences from parental traits and values.
Industry vs. inferiority (choice D) is a stage in which school age (6-12) children explore peer groups and learn that industry (hard work) generally pays off.
Intimacy vs. isolation (choice E) is the stage, in the early twenties, when young adults connect to their peers and significant others in a meaningful and mature way, putting aside fear and inhibitions.

Cough Case 1

A 50-year-old man consults a physician because he has developed a chronic, non-productive cough and is experiencing a reduced ability to do strenuous work. His symptoms have developed insidiously. On questioning, he states that he is a smoker and has also worked as a
contractor for all of his adult life. Physical examination is notable for the presence of repetitive end-inspiratory basal crackles and finger clubbing. A chest x-ray film shows diffusely distributed, small irregular opacities that are most prominent in the lower lung zones. Localized
areas of pleural thickening are also noted. No large masses are seen.

Q 1

The chest x-ray film is most consistent with which of the following?
/ A. Emphysema
/ B. Interstitial disease
/ C. Lobar pneumonia
/ D. Lung cancer
/ E. Pleural effusion

Q 2

The patient is sent for spirometry for further evaluation. FEV1 and FVC are both shown to be about 60% of the expected values, and the ratio of FEV1/FVC is 90%. These findings are most consistent with which of the following?
/ A. Asthma
/ B. Bronchiectasis
/ C. Chronic bronchitis
/ D. Emphysema
/ E. Restrictive lung disease


Q 3
The patient's work history is most suggestive of exposure to which of the following?
/ A. Asbestos
/ B. Beryllium
/ C. Coal
/ D. Kaolin
/ E. Silica

Q 4

In addition to predisposing for pulmonary fibrosis and bronchogenic carcinoma, this patient's disease is associated which of the following?
/ A. Basal cell carcinoma
/ B. Germ cell tumor
/ C. Hemangioma
/ D. Mesothelioma
/ E. Pleomorphic adenoma

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Cough Case 1 Answers

A1
The correct answer is B. Diffusely distributed small irregular opacities suggest the presence of interstitial lung disease.
Emphysema (choice A) would produce unusually dark lung fields.
Lobar pneumonia (choice C) would produce a "white out" of one or more lung lobes.
Lung cancer (choice D), if large, would produce a mass lesion (often involving a bronchus), or, if very small, might not be recognized on chest x-ray.
Pleural effusion (choice E) would cause a whitened area due to fluid below the lung

A2
The correct answer is E. Spirometry is commonly used to subdivide non-tumorous lung diseases into diseases that are predominately obstructive in nature and those that are predominately restrictive. The process of spirometry involves controlled breathing in and out while airflow is plotted against volume to obtain a continuous loop. FVC (forced vital capacity) is the maximum volume of air that can be forcibly and rapidly exhaled following a maximum inspiration. FEV1 (forced expiratory volume in the first second) is the volume of air expelled in the first second of a forced expiration starting from full inspiration. Restrictive lung disease usually shows a reduction in both FVC and FEV1, and the ratio of FEV1/FVC is greater than 80%. If these readings are obtained in a patient, further studies to measure lung volumes are usually performed to confirm the finding.
Asthma (choice A), bronchiectasis (choice B), chronic bronchitis (choice C), and emphysema (choice D) all tend to produce obstructive patterns, with FEV1 disproportionately decreased when compared to FVC.


A3

The correct answer is A. Working history often offers helpful clues about possible toxic exposures that may have contributed to lung disease. Asbestos was formerly a common constituent of insulating material in buildings because of both its insulating properties and its fire-resistant properties. People working on old buildings, particularly when removing the old insulation, are consequently vulnerable to high exposures unless they take care to minimize exposure with respirators. The risk to individuals living and working in old buildings is usually markedly less, since the asbestos is typically found behind walls. Individuals who work in asbestos mines (principally in Canada, South Africa, and the former USSR) may also have high exposures.
Beryllium (choice B) is used in the nuclear industry and in x-ray tubes, and was formerly used in ceramics, metallic alloys, and fluorescent lights.
Most significant coal (choice C) exposures occur in coal miners.
Kaolin (choice D) is a component of clay dust.
Silica (choice E) is found in sand and glass, and significant exposures can be seen in individuals working in environments where small particles of these materials may become aerosolized.

A4

The correct answer is D. Asbestos exposure is also linked to late (often after 20 years) development of the rare tumor, malignant mesothelioma. The amphibole forms of asbestos appear to be much more likely to induce mesothelioma than does chrysotile, and some authors have even speculated that the rare cases of mesothelioma in persons with predominant exposure to the serpentine form of asbestos may have been actually related to trace exposures to the amphibole forms. In contrast, all types of asbestos can cause pleural plaques, pulmonary fibrosis, and lung cancer. None of the other lesions listed in the choices have ties to asbestos.
Basal cell carcinoma (choice A) is a form of skin cancer.
Germ cell tumors (choice B) usually occur in testes and ovary.
Hemangioma (choice C) is a benign tumor of blood vessels.
Pleomorphic adenoma (choice E) is a salivary gland tumor.