1. Differential Diagnoses

2. 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

3. 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

4. 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

5. Diagnostics

6. HEMATOLOGY Laboratory Work-Up

7. 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 Hgb120-180g/L142g/LNORMAL Hct0.370-0.540%0.431%NORMAL MCV80-100fL89.4fLNORMAL MCH27-31pg29.5pgNORMAL MCHC320-360g/L329g/LNORMAL RDW-CV150-450 x 10­ 9 /L129 x 10­ 9 /LREDUCED Platelets2-4 x 10­ 11 /L3.1 x 10­ 11 /LNORMAL Neutrophil0.5-0.70.764SLIGHTLY ELEVATED Lymphocytes0.2-0.50.103REDUCED Monocyte0.02-0.090.082NORMAL Eosinophil0.0-0.060.047NORMAL Basophil0.0-0.020.004NORMAL APTT36.436.3NORMAL PT12-15 seconds12.5 secondsNORMAL

8. BLOOD CHEMISTRY Laboratory Work-Up

9. NormalJune 23, 2010Remarks BUN3.2-8.0 mmol/L2.46 REDUCED Creatinine53.133 umol/L71 ELEVATED Sodium135-145 mmol/L137 NORMAL Potassium4.0-4.5 mmol/L4.3 NORMAL Calcium2.12-2.75 mmol/L2.41 NORMAL Albumin38-51 g/L31 REDUCED AST0-34 U/L50 ELEVATED ALT0-30 U/L42 ELEVATED Total Bilirubin0-17.1 umol/L5.90 NORMAL Dir Bilirubin0-3.42 umol/L1.96 NORMAL Ind Bilirubin3.4-13.7 umol/L3.94 NORMAL Urate0.13-0.44 mmol/L0.31 NORMAL

10. URINALYSIS Laboratory Work-Up

11. NormalJune 23, 2010Remarks ColorYellowLight Yellow NORMAL TransparencyClear NORMAL SG1.016-1.0221.025 NORMAL Ph4.6-6.56.0 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

12. 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

13. CHEST X-RAY Imaging Studies

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

20. 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

21. SURGICAL PATHOLOGY Tissue Diagnosis

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

23. 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

24. AFB SPUTUM Culture

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

26. Diagnosis

27. 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.

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

29. http://www.hrpca.org/Bookletch19.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626451/ http://www.hrpca.org/Bookletch19.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626451/ http://www.chemocare.com/managing/hypoalbuminemia-low-albumin.asp http://www.medicinenet.com/esophageal_cancer/page3.htm#4whatare http://www.cancer.gov/cancertopics/factsheet/sites-types/head-and-neck#5 http://www.medicinenet.com/lung_cancer/page4.htm#toce http://www.emedicinehealth.com/pancoast_tumor/page3_em.htm#Pancoast Tumor Symptoms http://www.emedicinehealth.com/pancoast_tumor/page3_em.htm#Pancoast Tumor Symptoms http://emedicine.medscape.com/article/760301-overview http://www.medicinenet.com/superior_vena_cava_syndrome/page2.htm#tocd http://emedicine.medscape.com/article/177354-overview HPIM 17 th edition