Diagnosis of Lung cancer
Diagnostic Test list for Lung cancer:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Lung cancer
includes:
Lung cancer Diagnosis: Book Excerpts
Tests and diagnosis discussion for Lung cancer:
To help find the cause of symptoms, the doctor evaluates a
person's medical history, smoking history, exposure to
environmental and occupational substances, and family history
of cancer. The doctor also performs a physical exam and may
order a chest x-ray
and other tests. If lung cancer is suspected, sputum
cytology (the microscopic examination of cells obtained from a
deep-cough sample of mucus in the lungs) is a simple test that
may be useful in detecting lung cancer. To confirm the
presence of lung cancer, the doctor must examine tissue from
the lung. A biopsy
-- the removal of a small sample of tissue for examination
under a microscope by a pathologist
-- can show whether a person has cancer. A number of
procedures may be used to obtain this tissue:
-
Bronchoscopy .
The doctor puts a bronchoscope
(a thin, lighted tube) into the mouth or nose and down
through the windpipe to look into the breathing passages.
Through this tube, the doctor can collect cells or small
samples of tissue.
-
Needle
aspiration . A needle is inserted through the
chest into the tumor to remove a sample of tissue.
-
Thoracentesis .
Using a needle, the doctor removes a sample of the fluid
that surrounds the lungs to check for cancer cells.
-
Thoracotomy .
Surgery to open the chest is sometimes needed to diagnose
lung cancer. This procedure is a major operation performed
in a hospital.
(Source: excerpt from
What You Need To Know About Lung Cancer: NCI)
Diagnosis of Lung cancer: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Lung cancer:
Diagnostic Tests for Lung cancer: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Lung cancer.
HEMOPTYSIS:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there chest pain? If there is chest pain along with the hemoptysis, one should suspect a pulmonary embolism.
- Is there fever and/or purulent sputum? The presence of fever and purulent sputum suggests pneumonia, lung abscess, tuberculosis, and bronchiectasis. However, bronchiectasis does not usually occur with fever.
- Is there dyspnea, cardiomegaly, or a heart murmur? These findings suggest congestive heart failure or mitral stenosis.
- Is there copious sputum? The presence of copious sputum should suggest bronchiectasis or lung abscess. If there is fever along with it, lung abscess is more likely. Copious foamy sputum suggests congestive heart failure.
DIAGNOSTIC WORKUP
Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, coagulation profile, sputum smear, culture and sensitivity, a chest x-ray, and an EKG.
If a pulmonary embolism or infarction is suspected, arterial blood gases and a ventilation-perfusion scan should be ordered. In some cases, a pulmonary angiogram may be necessary. Objective testing for deep vein thrombosis with ultrasonography or impedance plethysmography may help confirm suspicion of a pulmonary embolism.
If tuberculosis is suspected, one should order a sputum or gastric washings for AFB smear, culture, and guinea pig inoculation. A tuberculin test should also be done. Apical lordotic views of the lung as well as lateral and oblique views may help identify a tuberculous cavity. There are serologic tests for antibodies against specific mycobacterial antigens.
Sputum cultures for fungi and skin tests for the various fungi may need to be done. If congestive heart failure is suspected, venous pressure and circulation time should be measured, and a pulmonary function test should be done. Echocardiography will help diagnose mitral stenosis.
A consultation with a pulmonologist and bronchoscopy need to be done if bronchogenic carcinoma or bronchiectasis is suspected. Other studies that are helpful in diagnosing bronchogenic carcinoma are sputa for Pap smear, transbronchial needle biopsy, and CT. MRI may confirm vascular etiologies for the bleeding such as pulmonary aneurysm. Serologic studies [ANA, antineutrophil cytoplasmic antibody (C-ANCA), etc.] may be useful in detecting collagen diseases. A bronchogram will be helpful in diagnosing bronchiectasis and foreign bodies.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hemoptysis:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Other sources of bleeding (e.g., hematemesis, epistaxis, and other causes of upper airway bleeding)
-
Airway disease is the most common cause of hemoptysis
–Bronchitis (acute or chronic) causes more than 25% of cases
–Cancers (metastatic and primary lung
cancers) cause up to 25% of all cases
–Bronchiectasis causes up to 10% of cases
–Foreign body
–Trauma
-
Parenchymal disease
–Infections: Tuberculosis (5%), pneumonia (5%), lung abscess, aspergilloma
–Coagulopathy: Anticoagulant use,
thrombocytopenia, DIC
–Cystic fibrosis
–Inflammatory: SLE, Wegener’s
granulomatosis, Goodpasture's syndrome
–Iatrogenic: Transbronchial or percutaneous lung biopsy, bronchoscopy, intubation
–Cocaine use
- Cardiovascular disease
–Pulmonary infarction/embolism
–Congestive heart failure
–Mitral stenosis
–AVM
–Trauma to pulmonary artery (e.g., Swan-
Ganz catheterization)
–Aortic aneurysm
–Osler-Weber-Rendu syndrome: Congenital
telangiectasias
-
Fistula formation between vasculature and airway
-
Catamenial hemoptysis (intrathoracic endometriosis): Cyclic bleeding with menses
-
Diffuse alveolar hemorrhage syndromes: ARDS, crack cocaine use, SLE, cytotoxic drug use
-
Inflammatory
–Behçet syndrome: Recurrent oral and genital ulcers, uveitis, and arthritis
–Henoch-Schönlein purpura: Most common systemic vasculitis in children; presents with palpable purpura, abdominal pain, hematuria, and arthritis
–Idiopathic pulmonary hemosiderosis - Idiopathic in 20% of cases
Workup and Diagnosis
-
Initial workup includes a chest X-ray; sputum for acid-fast stain, cytology and Gram stain/culture; pulse oximetry; PT/PTT; CBC; electrolytes; urinalysis; and BUN/creatinine
-
Consider respiratory isolation until TB is ruled out
-
Chest CT may show focal bleeding
-
Minor hemoptysis: Bronchoscopy is required if any risk factors for cancer are present, such as age >40, abnormal chest X-ray, hemoptysis >1 week, tobacco use (>40 pack-years), anemia, and/or weight loss
-
Major hemoptysis:
–Active bleeding requires immediate bronchoscopy
–Stable patients may undergo initial chest CT (if there is
no active bleeding) followed by bronchoscopy
–Bronchoscopy is both diagnostic and therapeutic—may localize bleeding and allow for balloon tamponade or vasoconstrictor injection at site of bleeding
-
Consider immunologic tests (e.g., ANCA for Wegener's syndrome; anti-GBM antibodies for Goodpasture's; ANA, anti-dsDNA, and low complement for SLE; ASO titer for poststreptococcal glomerulonephritis)
-
Arterial blood gas may be used to distinguish hemoptysis (alkaline serum pH) from hematemesis (acidic serum pH)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Hemoptysis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Think anatomically and physiologically of why we bleed and the source of the blood
-
Upper airway
–Nose bleed
–Chronic sinus disease
–Postoperative bleeding
–Dental disease
–Trauma (including CNS)
-
Digestive tract
–Esophageal varices
–Gastric bleeding (unlikely to come from intestine; that is, distal to antrum)
–Oral ulcers/trauma
-
Lower airways
–Tracheobronchial tree bronchiectasis (e.g., with CF)
–Bronchial erosion (e.g., from tracheotomy tube)
–Wegener granulomatosis
-
Parenchyma
–Pulmonary hemorrhage
–Pulmonary tuberculosis
–Lung abscess
–Hemorrhagic fevers (rare in U.S.)
–Paragonimiasis (a trematode infection)
–Lung contusion from trauma
–Primary pulmonary hemosiderosis
–Swyer-James syndrome
-
Cardiovascular causes
–Pulmonary embolism
–Multiple pulmonary telangiectasia (e.g.,
Osler-Weber-Rendu)
–Ruptured arteriovenous fistula
–Mitral stenosis
-
Bleeding disorders (may present from any source)
–Hemophilia, leukemia, and other blood dyscrasias
–Increased consumption of coagulation factors (e.g., disseminated vascular coagulation)
-
The most common source of blood originating in the lower airways is from small bronchial lesions secondary to inflammation from infection
Workup and Diagnosis
- History
–Recent surgery such as sinus surgery, tonsillectomy,
transbronchial biopsy
–Recent trauma
–Recent respiratory disease (e.g., choking episode
suggests FB, fever and productive cough suggest infection)
–Chronic illness suggests bronchiectasis, CF, chronic infection (e.g., TB)
–Chest pain associated with cough suggests tracheal disease (i.e., tracheitis)
–Association with gagging or emesis suggests Mallory-Weiss tear
–Association with liver or spleen disease suggests varices or decreased platelets
-
Physical exam
–Careful ENT evaluation for an upper airway source of bleeding
–Bleeding in other sites suggests bleeding disorder (e.g., joints, skin)
–Examine whole patient for signs of systemic disease
-
Labs
–Blood work may help: PT/PTT and CBC for anemia and/or thrombocytopenia
-
Flexible nasopharyngoscopy or bronchoscopy to evaluate airways
-
Chest X-ray to evaluate pulmonary hemorrhage
-
MRI may diagnose ectopic blood vessel in chest
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Source: In A Page: Pediatric Signs and Symptoms, 2007
HEMOPTYSIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The differential diagnosis of hemoptysis can be narrowed considerably by the clinical picture. Acute hemoptysis with chest pain would suggest pulmonary embolism. A chronic cough with occasional hemoptysis suggests neoplasm, tuberculosis, or bronchiectasis. Hemoptysis with chills and fever suggests pneumonia but one should always keep pulmonary embolism in mind. Hemoptysis with dyspnea, edema, or cardiomegaly suggests mitral stenosis or CHF. The sputum is usually foamy in cases of CHF. Hemoptysis with purpura or bleeding from other sites should suggest a systemic disease or coagulation disorder.
The initial workup of hemoptysis includes a CBC, urinalysis, sedimentation rate, chemistry panel, sputum smear and culture, and a chest x-ray. If a pulmonary embolism is suspected, arterial blood gas analysis and a lung scan are ordered. Pulmonary angiography may also be necessary. If routine studies and the clinical picture suggest pneumonia, nothing more may need to be done other than a careful follow up. If CHF is suspected, a circulation time may be done but a cardiology consult and echocardiogram would be more definitive. What would you do if it was your heart?
If a bronchogenic neoplasm or bronchiectasis is suspected, a pulmonary consult and bronchoscopy would be ordered. Bronchiectasis can be identified with a CT scan of the chest also. If tuberculosis is suspected, a tuberculin test is performed, and sputum is cultured for AFB and possibly Guinea pig innoculation performed.
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Source: Differential Diagnosis in Primary Care, 2007
Hemoptysis:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Introduction: Malignant Neoplasms:
Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))
A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).
An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:
❑as a baseline during chemotherapy to evaluate the extent of tumor spread
❑to regulate drug dosage
❑to prognosticate after surgery or radiation
❑to detect tumor recurrence.
Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Lung cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Typical clinical findings may strongly suggest lung cancer, but firm diagnosis requires further evidence.
❑Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear. It also indicates tumor size and location.
❑ Sputum cytology, which is 75% reliable, requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.
❑ Computed tomography (CT) scan of the chest may help to delineate the tumor's size and its relationship to surrounding structures.
❑ Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. The flexible fiber-optic bronchoscope increases the test's effectiveness.
❑ Needle biopsy of the lungs uses biplane fluoroscopic visual control to detect peripherally located tumors. This allows firm diagnosis in 80% of patients.
❑ Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsy. Directed needle biopsy may be performed in conjunction with CT scan.
❑Thoracentesis allows chemical and cytologic examination of pleural fluid.
Additional studies include preoperative mediastinoscopy or mediastinotomy to rule out involvement of mediastinal lymph nodes (which would preclude curative pulmonary resection).
Other tests to detect metastasis include bone scan, bone marrow biopsy (recommended in small cell carcinoma), CT scan of the brain or abdomen, and positron emission tomography.
After histologic confirmation, staging determines the extent of the disease and helps in planning the treatment and predicting the prognosis. (See Staging lung cancer.)
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hemoptysis:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? How much blood is he coughing up now and how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out which drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has recently had any infections or been exposed to tuberculosis. When was his last tine test and what were the results?
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum specimen and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hemoptysis:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Identification of the site of bleeding. What is the source of the bleeding? Is the problem truly hemoptysis or could the bleeding originate in a nonpulmonary location such as the nose and oropharynx or the gastrointestinal tract? Blood that is coughed from the respiratory tract is bright red in color and may be frothy or mixed with sputum. Hemoptysis is more likely with a history of underlying pulmonary disease, smoking, or mitral valve disease. Hematemesis is associated with blood that is dark red, brown, or coffee ground in appearance and that may be mixed with food particles. Hematemesis is favored in the presence of preexisting gastrointestinal condition, especially with a history of liver disease, alcohol use, or peptic ulcer disease. Sputum that is blood-streaked often arises from the nasal mucosa and oropharynx.
B. Characteristics of the sputum. What are the characteristics of the sputum in terms of color, odor, and consistency? A description of the sputum can assist in defining the disease process causing the hemoptysis: (a) frothy, pink sputum is suggestive of pulmonary edema fluid; (b) putrid or foul-smelling sputum suggests a lung abscess; (c) currant jelly sputum may suggest a necrotizing pneumonia; (d) the sputum of pneumococcal pneumonia is typically rust-colored and can be confused with true hemoptysis; (e) large amounts of blood-streaked sputum often suggest bronchiectasis.
C. Other information. Does the patient have other associated symptoms? Cough, dyspnea, and sputum production over several years may suggest chronic bronchitis or bronchiectasis. Weight loss and fatigue may suggest an underlying malignancy, and fever and night sweats might indicate tuberculosis. Does the patient have a history of known pulmonary, cardiac, or hematologic problems? Does the patient have hematuria, which might suggest a pulmonary-renal syndrome (Chapter 10.2)? Is the patient a smoker or have specific environmental exposures? Is the patient taking medications, especially anticoagulants, that might contribute to the bleeding?
Physical examination
A focused physical examination should include vital signs and examinations of the nose, sinuses, oropharynx, neck, lungs, and heart. The neck should be palpated for the presence of lymphadenopathy and inspected for jugular venous distension. The lower extremities should be checked for edema. Examination of the skin may reveal lesions associated with systemic lupus erythematosus; Kaposi’s sarcoma; clubbing (consistent with neoplasm, bronchiectasis, or lung abscess); or ecchymosis related to a coagulopathy.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hemoptysis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Bronchitis
❑ Pneumonia
❑ Pulmonary edema
❑ Pulmonary infarction
❑ Tuberculosis
❑ Bronchogenic carcinoma
❑ Chest trauma
❑ Bronchiectasis
❑ Bronchial adenoma
❑ A-V malformation
❑ Aspergilloma
❑ Vasculitis
❑ Lung abscess
❑ Mitral stenosis
❑ Hereditary hemorrhagic telangiectasia
❑ Parasitic
Diagnostic Approach
In primary care practice, neoplasm is the cause of less than 2% of cases of hemoptysis. A chest radiograph is nonetheless an essential component of the evaluation of every case of hemoptysis.
Differentiate hemoptysis from hematemesis. Hemoptysis is frothy, blood-tinged sputum that the patient can usually distinguish as coming from the lungs. Hematemesis is associated with nausea and vomiting, and it may be darker. Nasal or pharyngeal bleeding with posterior pharyngeal drainage could also be a source.
Clubbing indicates a chronic disorder and may be found in association with neoplasm, bronchiectasis, and lung abscess. Massive hemoptysis is usually due to lung cancer, tuberculosis, or aortic aneurysm.
Differential Diagnosis
Bronchitis Hemoptysis occurring in the setting of an acute vigorous productive cough suggests bronchitis, and is associated with typical upper respiratory symptoms.
Pneumonia Fever, cough tinged with blood, pleuritic chest pain, and focal rales with consolidative findings may occur in any combination. Pneumococcus classically produces rust-colored sputum. Klebsiella may produce a tenacious “currant jelly” sputum.
Pulmonary edema In acute left heart failure, frothy pink sputum occurs with dependent rales, S3 gallop, and dyspnea.
Pulmonary infarction In acute pulmonary embolism, sudden onset of pleuritic chest pain and dyspnea with a pleural rub will occur. A source may be found in a unilateral swollen leg.
Tuberculosis The classic presentation is blood-tinged sputum. Epidemiologic exposure/risk factors (e.g., being a health care worker, an Asian immigrant, or at risk for HIV) or upper lung field consolidative findings provide additional clues.
Bronchogenic carcinoma When presenting with hemoptysis, the lung cancer is usually primary because metastatic cancer is rarely endobronchial. Environmental exposure to tobacco or asbestos or a family history of this disease increases the risk. A firm, palpable supraclavicular node is sometimes found.
Chest trauma Rib fracture may cause a lung laceration. There will be exquisite tenderness over the rib segment, and the fragment will “float.”
Bronchiectasis It is recognized clinically by recurrent episodes of grossly bloody sputum (due to necrosis of bronchial mucosa) in a patient with chronic copious purulent sputum.
Bronchial adenoma Being quite vascular, these often present with episodes of self-limited hemoptysis recurrent over years.
A-V malformation There may be an audible bruit on auscultation of the lung.
Aspergilloma Suspect in an immunosuppressed host with prior cavitary lung disease or bullous disease with wheezing.
Vasculitis Goodpasture syndrome and Wegener granulomatosis are characterized by hemoptysis in association with hematuria. Wegener granulomatosis will be associated with a nasal septal ulcer or perforation.
Lung abscess Unmistakably fetid sputum will be intermittently mixed with blood.
Mitral stenosis Hemoptysis is a diagnostic pearl in a patient with a soft, low-pitched apical diastolic murmur and an opening snap. This condition is often not considered because of its rarity and the orientation toward considering pulmonary causes of hemoptysis.
Hereditary hemorrhagic telangiectasia Telangiectasias are evident on the lips and skin, and there is usually a history of bleeding from other sites.
Parasitic Schistosomiasis, paragonomiasis, or echinococcus should be considered in international travelers or immigrants.
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Source: Field Guide to Bedside Diagnosis, 2007
Lung cancer:
Diagnosis
(Handbook of Diseases)
Typical signs and symptoms may strongly suggest lung cancer, but a firm diagnosis requires further evidence, including the following:
❑ Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear. It also indicates tumor size and location.
❑ Sputum cytology is marginally helpful in obtaining a diagnosis. It requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.
❑ Computed tomography (CT) scan of the chest may help to delineate the tumor’s size and its relationship to surrounding structures.
❑ Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. The flexible fiber-optic bronchoscope increases the test’s effectiveness.
❑ A needle biopsy of the lungs uses biplane fluoroscopic visual control or CT guidance to detect peripherally located tumors. This allows a firm diagnosis in 80% of patients.
❑ Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsies.
❑ Thoracentesis allows chemical and cytologic examination of pleural fluid.
Additional studies include preoperative mediastinoscopy or mediastinotomy to rule out involvement of mediastinal lymph nodes (which would preclude curative pulmonary resection).
Other tests to detect metastasis include a bone scan, positron emission tomography scan, bone marrow biopsy (recommended in small cell carcinoma), and a CT scan of the brain or abdomen.
After histologic confirmation, staging determines the extent of the disease and helps in planning treatment and predicting the prognosis. (See Staging lung cancer.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Hemoptysis:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had any recent infections. Has he been exposed to tuberculosis? When was his last tine test and what were the results?
Physical examination
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Hemoptysis:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had any recent infections. Has he been exposed to tuberculosis? When was his last tine test and what were the results?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hemoptysis:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Neonates
Airway Trauma
Aggressive suctioning of trachea and mucosalinjury from endotracheal tube may cause mild tracheal bleeding,which is usually self-limited.
Pulmonary Hemorrhage
Sudden onsetof blood-tinged fluid oozing from trachea or endotracheal tube usually signifiespulmonary hemorrhage.Chest radiography shows diffuse scatteredinfiltrates in lung fields.Predisposing factors for pulmonaryhemorrhage include prematurity, perinatal asphyxia, neonatal respiratorydistress syndrome, pneumonia, pulmonary edema, and septicemia. Thesedisorders are discussed in other chapters. Bleeding Disorders
Pulmonary hemorrhage may occur in infantswho have bleeding disorders, particularly disseminated intravascularcoagulation. See Chap. 52, Purpuraand Bleeding.
Infants, Children, and Adolescents
Trauma
Injuriesto thorax may be blunt or penetrating. Automobile accidents aremost common cause of pulmonary compression injury.Damage to bronchi, blood vessels, orlung parenchyma may cause bleeding and respiratory distress.Rib fracture may lacerate lung parenchymaor pleura to produce bleeding.History, physical exam, and chest radiographare often diagnostic.Chest CT and bronchoscopy are usefulto determine location and extent of injury. Pulmonary Disorders
Bronchitis
Persistent hacking cough that occurs withacute or chronic bronchitis can produce blood-tinged sputum.
Pneumonia
Productivecough and blood-streaked sputum ("rusty sputum")can occur with pneumonia caused by pyogenic organisms (S. pneumoniae,H. influenzae type b, group A Streptococcus, S. aureus). M. tuberculosisis another cause of blood-streaked sputum.Fungal infection, especially aspergillosis,can produce parenchymal bleeding and erosion of major blood vessels.Viral pneumonia (influenza and varicella) are rare causes of hemoptysis.See Chap.10, Cough. Lung Abscess
Clinicalmanifestations of lung abscess include fever, cough with sputumproduction, and occasionally hemoptysis.Chest radiography may be diagnostic,but chest CT usually demonstrates abscess.See Chap.10, Cough. Bronchiectasis Including Cystic Fibrosis
Common findingin bronchiectasis is blood-streaked sputum because of local inflammationand persistent coughing.Cystic fibrosis is common cause ofbronchiectasis in pediatric population, and mild-to-massive bleedingcan occur.Local inflammation with mucosal ulcerationthat erodes wall of enlarged or tortuous bronchial artery is usuallysource of massive bleeding in cystic fibrosis. Foreign Body
Retained foreign bodies may cause airwayinflammation and bleeding. See Chap.10, Cough.
Idiopathic Pulmonary Hemosiderosis
Usuallyoccurs in early childhood.Clinical manifestations include cough,dyspnea, hemoptysis, and wheezing. Pallor and fatigue occur withsignificant iron deficiency anemia.Infiltrates resembling pneumonia butindicative of pulmonary hemorrhage may be seen on chest radiography.Clinical findings and presence of hemosiderin-ladenmacrophages in gastric aspirate, sputum, or bronchoalveolar lavagefluid are diagnostic. Pulmonary Hemosiderosis with Cow Milk Hypersensitivity
Pulmonaryhemorrhage may be associated with cow milk hypersensitivity in some cases.These children have circulating immunoglobulinG antibodies against cow milk proteins, increased serum immunoglobulinE levels, and often peripheral eosinophilia.Improvement usually occurs on dietfree of cow milk. Vascular Anomalies
Pulmonary Arteriovenous Malformation
Communicationof pulmonary artery or arteries with variable number of pulmonary veins.Bypass of pulmonary capillary bed leadsto arterial desaturation and cyanosis. Clubbing of fingers and toesand exercise intolerance are common. Systolic ejection or continuousmurmur may be heard on chest wall over malformation. If communicationis large, heart may be enlarged.Chest radiography shows ≥1 opacitiesof variable size in 1 or both lung fields.Cardiac catheterization and angiographyconfirm diagnosis. Hereditary Hemorrhagic Telangiectasia (Osler-Rondu-WeberDisease)
Multipletelangiectasias occur on skin and mucosa of respiratory and GI tractsin this autosomal-dominant disorder. Face, lips, ears, and fingersare especially affected.Spontaneous bleeding in respiratorytract can result in hemoptysis.Clinical findings and positive familyhistory are diagnostic.Most frequent form has been mappedto long arm of chromosome 9. Neoplasm
Primarypulmonary neoplasms, unusual in childhood and adolescence, commonly causechronic cough or wheezing and often some degree of respiratory distress.Benign bronchial tumors include papillomas, hemangiomas, fibromas,and adenomas. Malignant tumors include bronchogenic carcinoma andvarious sarcomas.Chest radiograph may show some degreeof atelectasis with an endobronchial lesion or a mass lesion ofthe pulmonary parenchyma.Chest CT defines location and extentof lesion.Bronchoscopy with biopsy may be diagnostic.Otherwise thoracoscopy or thoracotomy is necessary to obtain tissuefor histologic diagnosis. Cardiac Disorders
Pulmonaryedema precipitated by cardiac failure may produce pink, frothy,blood-tinged fluid. See Chap.7, Cardiac Failure.Other cardiovascular causes of hemoptysisare pulmonary atresia with ventricular septal defect (enlarged bronchialcirculation with thrombosis of small pulmonary arteries) and pulmonaryvascular disease. Goodpasture Syndrome
Association of pulmonary hemorrhage and glomerulonephritiswith antiglomerular basement membrane antibody is called Goodpasturesyndrome. Renal biopsy shows evidence of proliferative glomerulonephritisand characteristic linear immunoglobulin G deposition along glomerularbasement membrane.
Vasculitis
Systemic vasculitis disorders (e.g., systemiclupus erythematosus, Wegener granulomatosis, and Henoch-Schönleinpurpura) also may be associated with pulmonary hemorrhage. See Chap. 28, Hematuria.
Bleeding Disorders
Various bleeding disorders can produce hemoptysisin children of any age; however, there is usually other evidenceof bleeding. See Chap. 52, Purpuraand Bleeding.
Diagnostic Approach
Age of Onset
In neonates,blood in tracheal aspirate signifies mucosal bleeding from aggressive suctioning,trauma from endotracheal tube, or pulmonary hemorrhage. With thelatter, there is usually a history of perinatal asphyxia, neonatalrespiratory distress syndrome, or septicemia.In infants, children, and adolescents,blood in mouth or upper airway is most commonly due to epistaxis,gingivitis, tonsillitis, nasopharyngeal trauma, retching duringvomiting, or persistent cough. Most common causes of persistentcough and hemoptysis are bronchitis, bacterial pneumonia, and cystic fibrosis. Evaluation
CBC, includingplatelet count, and chest radiography should be performed in anyindividual with hemoptysis. Depending on suspected diagnosis, otheruseful tests include tuberculin skin test, prothrombin and activatedpartial thromboplastin times, and sputum culture for bacteria, tuberclebacilli, and fungi.With suspected heart disease, chestradiography, ECG, and 2-D echocardiography are often diagnostic.Sometimes cardiac catheterization and angiography are necessary.Laryngoscopy and bronchoscopy helpdistinguish between upper and lower respiratory tract bleeding.Bronchoscopy may diagnose foreign body or bronchial tumor. Materialfrom this procedure may be collected for culture, acid-fast stain,cytology, and Prussian blue stain. The latter can demonstrate hemosiderin-ladenmacrophages, which are seen in hemosiderosis.Chest CT helps locate and define extentof any respiratory tract or mediastinal mass. It also can diagnoseand define extent of bronchiectasis.Angiography of bronchial and pulmonaryarteries may demonstrate site of focal, unilateral, massive bleeding.Hemoptysis combined with other evidenceof bleeding usually signifies a bleeding disorder. Diagnostic approachto these disorders is discussed in Chap.52, Purpura and Bleeding.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hemoptysis:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he's receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?
Take the patient's vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient's chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum specimen and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HEMOPTYSIS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The differential diagnosis of hemoptysis can be narrowed considerably
by the clinical picture. Acute hemoptysis with chest pain would suggest
pulmonary embolism. A chronic cough with occasional hemoptysis suggests
neoplasm, TB, or bronchiectasis. Hemoptysis with chills and fever suggests
pneumonia, but one should always keep pulmonary embolism in mind. Hemoptysis
with dyspnea, edema, or cardiomegaly suggests mitral stenosis or CHF. The
sputum is usually foamy in cases of CHF. Hemoptysis with purpura or bleeding
from other sites should suggest a systemic disease or coagulation disorder.
The initial workup of hemoptysis includes a CBC, urinalysis, sedimentation
rate, chemistry panel, sputum smear and culture, EKG and chest x-ray. If a
pulmonary embolism is suspected, arterial blood gas analysis and a lung scan
are ordered. Pulmonary angiography may also be necessary. If routine studies
and the clinical picture suggest pneumonia, nothing more may need to be done
other than a careful follow-up. If CHF is suspected, a circulation time may
be done, but a cardiology consult and echocardiogram would be more
definitive. What would you do if it was your heart?
If a bronchogenic neoplasm or bronchiectasis is suspected, a pulmonary
consult and bronchoscopy would be ordered. Bronchiectasis can be identified
with a CT scan of the chest also. If TB is suspected, a tuberculin test is
performed, and sputum is cultured for AFB and possibly Guinea pig
inoculation performed.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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