Happy New Years everyone! Time for a new #TwitterReport!
We give you a case. You ask us questions. Everyone learns.
Case—
A 65yoM with HTN, CAD s/p stenting 7y ago presents with hemoptysis. He’s been filling a coffee mug up with blood q24h.
What else do you want to know?
@PittIMChiefs @IDPittStop @PittEMProgram @JMRocco5 @AkoczoAgnes @dwsamberg @s_w_fox @nievesra14 @Neethuabraham4 @senoramimi @cmallarino @zou_richard @RyanAugustinMD @UTSWIMchief @Brown_IM_Chiefs @MayoMN_IMRES @OHSUIMRes @JMAllenbaugh @BostonChiefs @TempleIM @TempleGIM @awfujita
@MFleshner301 @mgsimonson1 @cjchiu @DoctorWatto @PaulNWilliamz @thecurbsiders @BrighamSK @COREIMpodcast @PittCardiology @jelevenson @msenussiMD @human_dx @DxRxEdu @CPSolvers @medrants @aoglasser @DrKhanSolo @ArjunLakshman @dkleind1 @Doc_Olie @IMCreighton @laxswamy @LHortonGI
1/x #TwitterReport
HPI: Over last four months, patient reports
-night sweats,
-worsening non-productive cough, and a
-20 pound weight loss.
-Hemoptysis started two months ago as rusty sputum and he now coughs up enough bright blood to fill a coffee mug.
2/x #TwitterReport
HPI cont:
no time in jail. No homelessness. No time overseas.
Rare nosebleeds. Nothing new.
Social hx:
-no alcohol
-80 pack year smoking hx
-worked as a welder
Meds: metoprolol, ASA, atorvastatin, tamsulosin
PMH:
HTN
CAD s/p stents
BPH
3/x #TwitterReport
VS: BP 140/80, HR 65, SpO2 95% room air
Comfortable appearing
Pulm: rhonchi in LLL
HEENT: no blood easily seen
WBC 12, no left shift
Hb 13 from 15 2 years ago
Plt 350
BMP is normal including BUN:Cr
4/x #TwitterReport
Chest x-ray is shown.
What do you want to do? Can I get a summary statement, please? What do you think is going on?
@PittIMChiefs @IDPittStop @PittEMProgram @JMRocco5 @AkoczoAgnes @dwsamberg @s_w_fox @nievesra14 @Neethuabraham4 @senoramimi @cmallarino @zou_richard @RyanAugustinMD @UTSWIMchief @Brown_IM_Chiefs @MayoMN_IMRES @OHSUIMRes @JMAllenbaugh @BostonChiefs @TempleIM @TempleGIM @awfujita
@MFleshner301 @mgsimonson1 @cjchiu @DoctorWatto @PaulNWilliamz @thecurbsiders @BrighamSK @COREIMpodcast @PittCardiology @jelevenson @msenussiMD @human_dx @DxRxEdu @CPSolvers @medrants @aoglasser @DrKhanSolo @ArjunLakshman @dkleind1 @Doc_Olie @IMCreighton @laxswamy @LHortonGI
5/x #TwitterReport
Great discussion folks!
Our summary: 65yoM with chronic constitutional symptoms incl unintentional weight loss and an 80ppy smoking history p/w a cavitary lung lesion, TB risk factors and testing neg.
CT Chest- LLL cavity, mediastinal LAD, LUL 2cm nodule
6/x #TwitterReport
Other results:
ENT scope— no epistaxis
Bronch- minor LLL blood, no pus
Sputum + BAL GS/culture— no bugs
AFB sputum/Cx x3— no AFB
All fungal serologies— neg
HIV— neg
ANCA—neg
ANA— neg
RF— neg
7/x #TwitterReport
Tests for cancer:
BAL cytology— neg for malignancy
Brushings— neg
FNA— neg
What now? What’s high on your differential? What’s lower? If cancer was your #1 diagnosis, what’s your #1 diagnosis now?
@CPSolvers @ImproveDX
@MFleshner301 @mgsimonson1 @cjchiu @DoctorWatto @PaulNWilliamz @thecurbsiders @BrighamSK @COREIMpodcast @PittCardiology @jelevenson @msenussiMD @human_dx @DxRxEdu @CPSolvers @medrants @aoglasser @DrKhanSolo @ArjunLakshman @dkleind1 @Doc_Olie @IMCreighton @laxswamy @LHortonGI
@PittIMChiefs @IDPittStop @PittEMProgram @JMRocco5 @AkoczoAgnes @dwsamberg @SteveFox432 @nievesra14 @Neethuabraham4 @senoramimi @cmallarino @zou_richard @RyanAugustinMD @UTSWIMchief @Brown_IM_Chiefs @MayoMN_IMRES @OHSUIMRes @JMAllenbaugh @BostonChiefs @TempleIM @awfujita
8/x #TwitterReport
Sorry for the late conclusion, but here it is!
So as many of you said (@laxswamy @sbelok01 @williammflowers), this patient gets more biopsies
1) CT guided-FNA --> negative for cancer
2) Finally goes for EBUS --> positive for squamous cell lung cancer
9/x #TwitterReport
Final diagnosis: Locally metastatic lung cancer, squamous histology
...
"Wait, what?" many of you are probably saying. "He got FOUR negative samples before a cancer diagnosis was established! How does that work?"
To explain, let's talk test characteristics!
10/x #TwitterReport
What was your pretest probability of Lung Ca. in this patient (with an 80ppy smoking history, weight loss, hemoptysis, cavitary lung nodules)?
Probably really high, right? 90% sound reasonable?
***In every case, consider how likely you think the dx is!**
11/x #TwitterReport
Now: How good are all these tests for detecting lung malignancy?
-Specificity: ~100% (you can't fake cancer... usually)
-Sensitivity: not great
The result is a negative likelihood ratio that is >0.2 for all tests. Not Great at ruling out malignancy!
12/x #TwitterReport
If your pretest probability is high enough, even multiple negative tests won't move your post-test probability that further down!
That's why the 2013 Chest Guidelines recommend that you keep looking for cancer if your suspicion is high enough!
13/13 #TwitterReport
Final note: All those serologies you want to order are probably useless....
Except for the ANCA. The ANCA has a great positive predictive value even in the absence of other symptoms.
So in the end, it just all comes back to the history!
Questions?
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