darkhorse
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A 56-year-old man comes to the clinic for a pre-employment physical examination. He feels well and denies any health problems. Past medical history is negative except for an appendectomy about 20 years ago. The patient drinks several alcoholic beverages per day and smokes "a lot" of cigarettes. A "screening" chest x-ray, which you ordered because it is asked for on the employment forms, is shown below and demonstrates a left hilar mass and emphysema. In considering the most appropriate next step in management, the most relevant question to ask this patient at this time is:
A. "Are your affairs in order?"
B. "Do you have any allergies?"
C. "How many packs of cigarettes do you smoke per day?"
D. "What are your thoughts on end of life care?"
E. "Would you consent to a lung biopsy?"
F. "Would you consider chemotherapy or radiation treatment for cancer?"
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| Kamsi
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D
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| Justice
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E. "Would you consent to a lung biopsy?"
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| darkhorse
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 thats not correct guys
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| jvo_md
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I think E is the most pertinent Qs
Why D KAmsi? 
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| jvo_md
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but io also thought of answer C at first...
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| jvo_md
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whats the answer darkhorse?
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| cool doctor
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c?
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| jvo_md
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Yes....because you dont know yet for how long he had been smoking ....and the time is also related to Lung CA
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| darkhorse
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Explanation: The correct answer is B. The chest x-ray demonstrates a right mid-lung nodule and emphysema. There is a lung nodule that is likely to be cancer in this patient with a smoking history and radiographic emphysema. The next step is a CT scan of the thorax with contrast, and before administering iodinated contrast, an allergy history must be elicited. Prior allergies to iodinated contrast material or shellfish will require further questioning. If the allergy is minor such as mild hives, pruritus, or flushing, a pre-medication regimen of prednisone and diphenhydramine is necessary. More serious allergies such as anaphylaxis preclude the administration of intravenous contrast.Questions about death (choice A and D) are premature. This nodule may be an artifact, pneumonia, a granuloma, or cancer. Moreover, a localized cancer may be curable.While quantification of the patient's smoking (choice C) is necessary for a complete history, it does not change the management of this patient.A lung biopsy (choice E) is premature. A CT scan and possibly PET scan are necessary to evaluate this lesion noninvasively before an invasive procedure is carried out.Even though this nodule is likely to be cancer, questions about cancer treatment (choice F) are premature.
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