Differential Diagnoses

Differential DiagnosisRule InRule Out LymphomaEnlarging cervical mass and axillary lymph node, exposure to benzene (tricycle driving & smoking), wt loss Cannot be ruled out TBCough, wt loss, exposure to TB (father & sister) Cannot be ruled out Laryngeal CA (w/ lymphatic spread) Enlarging cervical mass, cough, hoarseness, difficulty swallowing, wt loss, smoking history Cannot be ruled out

Differential Diagnoses Differential DiagnosisRule InRule Out Esophageal CA (w/ lymphatic spread) Enlarging cervical mass, difficulty swallowing, cough, wt loss, smoking history Cannot be ruled out Cancer of the Throat (w/ lymphatic spread) Enlarging cervical mass, hoarseness, difficulty swallowing, cough, wt loss, smoking history Cannot be ruled out Lung CA (w/ lymphatic spread) Cough, hoarseness, wt loss, shoulder pain, difficulty swallowing, smoking history, enlarging cervical mass Cannot be ruled out

Differential Diagnoses Differential DiagnosisRule InRule Out Pancoast tumor (w/ lymphatic spread) Shoulder pain, wt. lossCannot be ruled out Superior Vena Cava Syndrome Facial edema, hoarseness, cough, enlarging neck mass Cannot be ruled out PneumoniaOccasional productive cough No other associated signs and symptoms (fever, chills, fatigue, malaise, headache, chest pain

Diagnostics

HEMATOLOGY Laboratory Work-Up

NormalJune 23, 2010Remarks WBC4-11 x 10­ 9 /L8.08 x 10­ 9 /LNORMAL RBC4-6 x 10­ 9 /L4.82 x 10­ 9 /LNORMAL Hgb g/L142g/LNORMAL Hct %0.431%NORMAL MCV80-100fL89.4fLNORMAL MCH27-31pg29.5pgNORMAL MCHC g/L329g/LNORMAL RDW-CV x 10­ 9 /L129 x 10­ 9 /LREDUCED Platelets2-4 x 10­ 11 /L3.1 x 10­ 11 /LNORMAL Neutrophil SLIGHTLY ELEVATED Lymphocytes REDUCED Monocyte NORMAL Eosinophil NORMAL Basophil NORMAL APTT NORMAL PT12-15 seconds12.5 secondsNORMAL

BLOOD CHEMISTRY Laboratory Work-Up

NormalJune 23, 2010Remarks BUN mmol/L2.46 REDUCED Creatinine umol/L71 ELEVATED Sodium mmol/L137 NORMAL Potassium mmol/L4.3 NORMAL Calcium mmol/L2.41 NORMAL Albumin38-51 g/L31 REDUCED AST0-34 U/L50 ELEVATED ALT0-30 U/L42 ELEVATED Total Bilirubin umol/L5.90 NORMAL Dir Bilirubin umol/L1.96 NORMAL Ind Bilirubin umol/L3.94 NORMAL Urate mmol/L0.31 NORMAL

URINALYSIS Laboratory Work-Up

NormalJune 23, 2010Remarks ColorYellowLight Yellow NORMAL TransparencyClear NORMAL SG NORMAL Ph NORMAL Sugar(-) NORMAL Albumin(-) NORMAL RBC0-2/hpf4/hpf MICROSCOPIC HEMATURIA WBC0-5/hpf2/hpf NORMAL Casts3/hpf Bacteria(-)1/hpf POSSIBLE INFECTION Ketones(-)+1 KETONURIA

Differential Diagnoses Differential Diagnosis Rule InRule Out PneumoniaOccasional productive cough No other associated signs and symtoms; no sign of infection based on hematology Liver CAReduced liver function Cannot be ruled out Liver damageReduced liver function Cannot be ruled out KetoacidosisKetones in the urine, reduced food intake, wt loss Cannot be ruled out

CHEST X-RAY Imaging Studies

MULTIPLE CONTIGUOUS AXIAL CT SCAN OF THE CHEST WITH IV CONTRAST Imaging Studies

Imaging Results Well defined lobulated pulmonary mass with irregular margin with eccentric calcifications at the superior basal segment of the left lower lobe <1cm pulmonary nodule at the posterior basal segment of the right lower lobe With either linear fibrosis or subsegmental atelectasis at the anterobasal segment of the left lower lobe Pleural thickening, left lung Thoracic spondylosis No liver metastasis

SURGICAL PATHOLOGY Tissue Diagnosis

April 26, 2010 Malignant columnar cells forming a papilloid pattern, with large nuclei and scanty cytoplasm, suggestive of metastatic poorly undifferentiated adenocarcinoma

SCLC vs. NSCLC SCLCNSCLC Scant cytoplasmAbundant cytoplasm Hyperchromatic nuclei w/ fine chromatin pattern Pleomorphic nuclei w/ coarse chromatin pattern Indistinct nucleoliProminent nucleoli Diffuse sheet of cellsGlandular or squamous architechture

AFB SPUTUM Culture

June 26, 2010 Day 1: (-) AFB Day 2: (-) AFB Day 3: (-) AFB

Diagnosis

Working Diagnosis Lung cancer, non-small cell (adenocarcinoma), stage 4, currently undergoing cobalt radiotherapy with possible malnutrition and pulmonary TB. To consider kidney and liver damage.

Pain when swallowing Decreased food intake GuconeogenesisMuscle wastingHypoalbuminemiaElevated AST, ALP Ketone body production

Tumor Symptoms Tumor Symptoms HPIM 17 th edition