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?
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.
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
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
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?
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
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
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
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
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!
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!**
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!
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!
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?
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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