anastamosis
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A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia. Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia. All the episodes were successfully treated with intravenous antibiotics. Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar. The scar was not noted on the chest x-ray prior to the episodes of pneumonia. He has a 50-pack year history of smoking. He quit smoking 10 years ago.
Which of the following is the most useful test to confirm the diagnosis in this patient?
A. Sputum for cytology and AFB staining
B. Bronchoalveolar lavage for hemosiderin laden macrophages
C. Flexible bronchoscopy
D. Immunoglobulin levels
E. High resolution CT scan
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| sprint123
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Post-obstructive pneumonia ----> HRCT
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| Ivonne
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I am thinking in lung cancer
E
Edited by Ivonne on 01/05/08 - 07:32 PM
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| hero
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Ivonne wrote:
I am thinking in lung cancer
E
the most useful to confirm?
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| anastamosis
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yes i think thats why they say the answer to be C.
Good observation HERO
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| drduck
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i dont know what is asked in the question........is it that how shud one diagnose pmeumonia, i mean microscopically....or is it some thing else..
when i saw the Q my answer was haemosiderin laden macrophages..
but the Q is asking something else...
i realised, they were asking the reason for the recurrent episodes of pnemonia that too why always ON THE SAME LOCATION.
i think the answer has to be C....
the reason why patient has recurrent episodes with same location always is that patient has a strong history of smoking.
and so will have LESS NUMBER OF CILIA IN REMOVE SECRETION.
or in other words he has a POOR MUCO-CILIARY CLEARENCE.
so he becomes a strong candidate for RECURRENT ASPIRATION SYNDROME.
during sleep he will often aspirate his mucous leading to recurrent pnemonia at the same site which is the comment site for aspiration when patient is supine.
and to diagnose the mucociliary activity or quantity of cilia the best way is to go for a FLEXIBLE BRONCHOSCOPY.
and that is why C must be the answer.
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| neurom
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Lung cancer - C.
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| anastamosis
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drduck, aspiration pneumonia more common in people with impaired mentation. liek alcoholics, stroke patients etc
Smoker = Lung CA, UPO !!
The most useful to confirm is FLEXIBLE BRONCHOSCOPY, while the best next step in this patient would be HRCT.
Hope this helps
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| drduck
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i agree to what u say.......but the hints or information given in the Q points towards aspiration.
also check the location of injury or damage......it is the m/c site for aspiration.
but, u are correct....it has to be a malignancy....cos chronic aspiration pneumonia or scarring over years and positive h/o smoking....suggests more towards malignancy......that too SQUAMOUS CELL CARCINOMA
but still answer will remain the same.....that is C.....it has to be flexible bronch....as the commonest location of this tumor is CENTRAL....which can be easily visualised and biopsied for diagnosis of the same.
adenocarcinoma is more of peripheral location so diagnosis will require percutaneous biopsy that too CT guided.
no one cud diagnose cancers radiologically like HRCT, they just help in knowing the extent of tumor and its staging.
thanks anyway...that really helped
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| mildus
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I agree it should be C; recurrent pneumonia always at the same place is very suggestive for lung cancer
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| Korotkoff
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Can this be bronchiectasis? It doesn't change the answer. It will be still C.
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| lucky_doc
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Sounds like bronchiectasis . Here is the explanation
High resolution CT is the diagnostic test of choice
Bronchiectasis
Essentials of Diagnosis
Chronic productive cough with dyspnea and wheezing.
Recurrent pulmonary infections requiring antibiotics.
A preceding history of recurrent pulmonary infections or inflammation, or a predisposing condition.
Radiographic findings of dilated, thickened airways and scattered, irregular opacities.
General Considerations
Bronchiectasis is a congenital or acquired disorder of the large bronchi characterized by permanent, abnormal dilation and destruction of bronchial walls. It may be caused by recurrent inflammation or infection of the airways and may be localized or diffuse. Cystic fibrosis causes about half of all cases of bronchiectasis. Other causes include lung infection (tuberculosis, fungal infections, lung abscess, pneumonia), abnormal lung defense mechanisms (humoral immunodeficiency, 1-antiprotease deficiency with cigarette smoking, mucociliary clearance disorders, rheumatic diseases), and localized airway obstruction (foreign body, tumor, mucoid impaction). Immunodeficiency states that may lead to bronchiectasis include congenital or acquired panhypogammaglobulinemia; common variable immunodeficiency; selective IgA, IgM, and IgG subclass deficiencies; and acquired immunodeficiency from cytotoxic therapy, AIDS, lymphoma, multiple myeloma, leukemia, and chronic renal and hepatic diseases. However, most patients with bronchiectasis have panhypogammaglobulinemia, presumably reflecting an immune system response to chronic airway infection. Acquired primary bronchiectasis is now uncommon in the United States because of improved control of bronchopulmonary infections.
Clinical Findings
Symptoms and Signs
Symptoms of bronchiectasis include chronic cough with production of copious amounts of purulent sputum, hemoptysis, and pleuritic chest pain. Dyspnea and wheezing occur in 75% of patients. Weight loss, anemia, and other systemic manifestations are common. Physical findings are nonspecific, but persistent crackles at the lung bases are common. Clubbing is infrequent in mild cases but is common in severe disease. Copious, foul-smelling, purulent sputum is characteristic. Obstructive pulmonary dysfunction with hypoxemia is seen in moderate or severe disease.
Imaging
Radiographic abnormalities include dilated and thickened bronchi that may appear as "tram-tracks" or as ring-like markings. Scattered irregular opacities, atelectasis, and focal consolidation may be present. High-resolution CT is the diagnostic study of choice.
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| neurom
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Right Middle Lobe Syndrome. First they want us to think of endobronchial tumor---> bronchoscopy helps to rule it out..
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| farnsworth
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C: bronchoscopy is the most useful test to confirm the diagnosis (tissue sampling!)
if recurrent pneumonic infiltrations occur in the same lobe (seen on CXR), proceed with HRCT (E), use bronchoscopy for tissue sampling (C)
(the Hx is highly suggestive of post-obstruction pneumonia, since it is confined to the right middle.
regarding the other possible diagnoses:
- bronchiectasis: usually involves the complete lung
- recurrent aspiration syndrome: usually affects right lower lobe, does not leave scars. a decreased mucociliare clearance alone usually does not lead recurrent aspiration syndrome (failure of clearance of pulmonary secretions is per definition no aspiration, but secretion retention).
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