Hi group 2:

this was probably too easy for you!

You nailed the dx. This is a 68-year-old woman with a medical history significant for tobacco use for more than 25 years who presents to the emergency room with hemoptysis, cough, reduced appetite, and weight loss. The most likely diagnosis in this case is lung cancer. On physical examination, there was clubbing. Finger clubbing is defined as an enlargement of the terminal digital phalanges with loss of the nail bed angle. Clubbing of the fingers is seen in a variety of conditions, including congenital heart disease and a number of pulmonary diseases. Clubbing can also be congenital and unassociated with any disease. In pulmonary disease, clubbing of fingers is most commonly seen in patients with lung cancer or with chronic septic conditions, such as bronchiectasis or lung abscess. Finger clubbing is not commonly seen in patients with chronic obstructive lung disease or chronic tuberculosis; its appearance in patients with these conditions should lead to suspicion of tumor development. Our patient's finger clubbing is, therefore, another element on physical examination that reinforces the suspicion of lung cancer.

The manifestation (symptoms and signs of lung cancer) depends on the tumor's location and the type of spread. Some patients may be completely asymptomatic. In these cases, a lung nodule usually is found on routine chest x-ray. Most primary lung tumors are endobronchial. Therefore, patients typically present with cough with or without hemoptysis. In patients with chronic bronchitis, increases in intensity and intractability of the existing cough may suggest the presence of malignancy. Sputum production usually is not excessive, but occasionally it may he watery and profuse, as in alveolar cell carcinoma, and often is blood-streaked. Chest pain is also a possible symptom of lung cancer and suggests the neoplastic invasion of the chest wall. Symptoms of weight loss. malaise, and fatigue usually develop later in the disease course. Malignant serosanguineous pleural effusion is common and often large and recurrent. Patients may present with a complaint of chest pain and an increasing shortness of breath. Horner syndrome is caused by the invasion of the cervicothoracic sympathetic nerves and occurs with apical tumors (Pancoast tumor). Phrenic nerve invasion may cause diaphragmatic paralysis. SVC obstruction is produced by direct extension of the tumor or by compression from the neighboring lymph nodes. SVC syndrome has a dramatic clinical presentation and requires urgent care. Small cell lung cancer and squamous cell lung cancer frequently cause SVC syndrome.

Good work!

Jack