For each set of patients below, select the most likely diagnosis.
a. Laryngeal carcinoma
b. Small cell carcinoma of the lung
c. Large cell carcinoma of the lung
d. Beryliosis
e. Sarcoidosis
f. Laryngeal papilloma
g. Bronchial adenoma
h. Cystic fibrosis
i. Hodgkin’s disease
j. Chronic obstructive lung disease
k. Acute bronchitis
135. A 20-year-old male has a cough and history of bronchitis with thick
greenish sputum. There is no history of cigarette smoking. The patient has
also been treated for abdominal cramping and malabsorption.
136. A 60-year-old black male who has a long history of cigarette smoking
and alcohol abuse complains of pain on swallowing. Pain is also
referred to the ear. The patient speaks with a hoarse voice.
137. A 55-year-old women, who began smoking cigarettes as a teenager,
has been losing weight for 3 months and complains of hemoptysis and
cough. She has also had 1 week of severe leg and back pain. Routine laboratory
data shows hyponatremia and anemia.
138. A 40-year-old electronics worker has noted increasing shortness of
breath and cough over many years, which he attributes to working conditions.
On physical exam there is dermatitis of the face and bilateral inspiratory
crackles. Chest x-ray shows hilar adenopathy and bilateral
interstitial markings.
139. A 42-year-old male is evaluated for fever, night sweats, and pruritus.
There is a 2-cm fixed supraclavicular node on physical exam as well as
bilateral axillary nodes. Chest x-ray shows mediastinal lymphadenopathy.
The answers are 135-h, 136-a, 137-b, 138-d, 139-i.
(Kasper, pp 506–516, 654, 1489, 1524, 1543–1546.) The 20-year-old male
has evidence of chronic airway infection not associated with cigarette
smoking. Cystic fibrosis is a multisystem disease with signs and symptoms
usually beginning in childhood. However, 7% of patients are diagnosed as
adults. This is an autosomal recessive disease with a gene mutation on
chromosome 7. In addition to respiratory tract infection, there are intesti-
nal complications and exocrine pancreatic insufficiency. This results in
malabsorbtion with bulky stools.
The 60-year-old black male presents with symptoms of laryngeal carcinoma.
The disease is closely correlated with smoking. Alcohol is also an
important risk factor, and the disease is more common in blacks than
whites. Symptoms depend on the anatomic region of the cancer. Pain on
swallowing is the most common symptom, sometimes with dysphagia or a
mass sensation. For glottic and subglottic tumors, hoarseness is often
present. Pain may also be referred to the ear by the recurrent laryngeal
nerve.
The incidence of small cell carcinoma of the lung is increasing in
women. The 55-year-old woman suggests the diagnosis of small cell carcinoma
because symptoms have developed quickly and there is evidence for
early metastatic disease. In addition, the syndrome of hyponatremia caused
by inappropriate ADH secretion is more likely to occur with small cell carcinoma.
The 40-year-old electronics worker is an example of environmental
lung disease. Berylliosis occurs in the high-tech electronics field as well as
in the manufacture of alloys, nuclear material, and ceramics. Usually, 2 to
15 years of exposure are required before becoming symptomatic. Dermatitis
may be present, along with nonspecific respiratory symptoms. This is a
granulomatous disease presenting in a manner similar to sarcoidosis. Tissue
levels of beryllium can be measured for definitive diagnosis.
The 42-year-old with fever, night sweats, and pruritus gives symptoms
very characteristic of Hodgkin’s disease. Most patients present with palpable
lymphadenopathy, and more than half will have mediastinal lymphadenopathy
on presentation. About half will have symptoms of fever,
night sweats, or weight loss. There may be unexplained itching as well as
cutaneous lesions such as erythema nodosum, or icthyosis.
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