A 75-year-old woman presents with confusion, dehydration, and constipation. She is found to have hypercalcemia and is admitted for observation and further testing. A new chest x-ray reveals a right hilar mass. A whole body PET-CT scan reveals no evidence of mediastinal lymph node involvement or distant metastasis. What is the most likely explanation for hypercalcemia in this patient?
a. Hypertrophic pulmonary osteoarthropathy secondary to adenocarcinoma of the lung
b. Paraneoplastic syndrome secondary to small cell lung carcinoma
c. Paraneoplastic syndrome secondary to squamous cell lung carcinoma
d. Osteolytic bony lesions secondary to adenocarcinoma of the lung
e. Recent emergence of Cushing syndrome
The most correct answer is c, paraneoplastic syndrome secondary to squamous cell carcinoma of the lung.
Answer a is incorrect, inasmuch as hypertrophic pulmonary osteo-arthropathy secondary to adenocarcinoma of the lung is generally not associated with hypercalcemia even though osseous structures are involved by periostitis and digital clubbing. Answer b is unlikely because unlike most paraneoplastic syndromes that are associated with small cell lung carcinomas, hypercalcemia is most common among patients with squamous cell lung cancer. Answer d is incorrect here because metastatic disease to the bones has already been excluded by the PET-CT scan findings. Answer e is not applicable here because the spectrum of laboratory abnormalities in Cushing syndrome generally does not include hypercalcemia.
A 75-year-old man with a 60-pack year history of tobacco abuse presents with progressive dyspnea of 4 weeks. He has a history of nonproductive cough, anorexia, and 8 kg weight loss, but denies fever, chills, or night sweats. On physical exam, he has normal vital signs; jugular venous pressure is normal. There is no lymphadenopathy. Cardiac exam shows decreased heart sounds but no other abnormality. On pulmonary exam, the patient has dullness over the left lower lung field, decreased tactile fremitus, and decreased breath sounds. The right lung examination is normal. Chest x-ray shows consolidation in the left lung with moderate pleural effusion. What is the most appropriate management of this patient at this point?
b. CT guided needle biopsy
c. Inhaled bronchodilators
d. Intravenous antibiotics
The most correct answer is e, thoracentesis.
This patient with a long-standing history of exposure to tobacco products and thereby at risk for pulmonary malignancy is symptomatic with shortness of breath and physical findings consistent with his radiographically demonstrable left-sided pleural effusion. Answer a, bronchoscopy, is not the recommended initial diagnostic procedure because thoracentesis may both improve the patient's dyspnea even while providing diagnostic material to help establish whether the pleural effusion is due to a malignant cause, which if the case, would represent M1a disease. Answer b, CT guided needle biopsy is not appropriate here considering the presence of readily obtainable pleural fluid by thoracentesis. Answer c, inhaled bronchodilators is not the most appropriate management at this point in view of the lack of wheezing on physical examination. Similarly, answer d represents empiric treatment for pneumonia. Yet, the patient is without fever or chills to support that diagnosis; such treatment is also unlikely to improve the patient's symptoms acutely and will not furnish diagnostic material for additional study.
A 50-year-old woman presents to her oncologist for evaluation prior to treatment of a recently diagnosed adenocarcinoma of the lung that is unresectable due to contralateral mediastinal lymph node involvement. She complains of difficulty opening her car door while in the driver's seat, but no problem opening the car door when in the passenger's seat. She denies headaches, visual changes, nausea, vomiting, arthralgias, rashes, sensory changes, or weakness involving other extremities. On exam, she has subtle left upper extremity weakness manifested by a pronator drift on the left. Muscular tone and reflexes seem normal. What is the most likely cause of her symptoms?
a. Hypertrophic pulmonary osteoarthropathy secondary to her lung cancer
b. Lambert-Eaton myasthenic syndrome secondary to her lung cancer
c. Polymyositis secondary to her lung cancer
d. Hypercalcemia secondary to her lung cancer
e. Brain metastasis secondary to her lung cancer
The most correct answer is e, brain metastasis.
Answer a would be an unlikely explanation of the patient's focal neurological deficit that is limited to the left upper extremity, inasmuch as the chief features of hypertrophic pulmonary osteo-arthropathy are symmetrical, painful, proliferative periostitis in association with digital clubbing. Similarly, answer b is incorrect, considering that Lambert-Eaton myasthenic syndrome presents in a generally symmetric manner with associated autonomic dysfunction and cranial nerve deficits, rather than isolated weakness of an extremity. Again, answer c, polymyositis, is not an appropriate response here because of the focal nature of the patient's symptoms and lack of muscular tenderness. Answer d, hypercalcemia is incorrect in this instance considering the lack of associated symptoms of confusion or constipation and the physical examination which is not remarkable for signs of dehydration.