Monday, October 31, 2005

Abnormal CxR

We were asked to see this 74 y/o woman for dyspnea and atypical chest pain. She has a long TOB Hx (>50 p/y) and continues to smoke. Last year she had a "lump" in her neck (it was benign) and had an unremarkable neck and chest CT scan. For the past 2 weeks she has had worsening dyspnea and a cough productive of blood-streaked clear sputum.
No othe significant PMHx or exposures.
Her exam reveals decreased BS on the L with faint crackles and her CxR is seen below:

What would you do next?

6 comments - CLICK HERE to read & add your own!:

Mike L said...

The resolution on my monitor is poor, but it looks like you have a LLL posterior lesion with tracheal deviation to the left. I MAY see the sudden cuttoff of the left lower lobe bronchus (just below the mainstem), but I cannot be sure if it is artifact.
I would be worried about an endobronchial lesion causing lobar atelectasis.
She needs a CT scan, I would send sputum cytology if she is coughing anything up.
Ultimately, a bronch would probably be necessary

Mendez said...

Looks like there is pretty significant LLL collapse with resultant traction as noted by tracheal shift on AP. I'm having trouble making out the lateral (in terms of layering). Either way an U/S would be helpful to quantify fluid and if there is a significant amount aspirat for cytology and culture. Additionally, a CT may be indicated to better delineate any pleural abnormalities.

However, I do suspect a bronchogenic lesion causing collapse and shift. Ultimately, bronchoscopic AW exam with Bx would be necessary.

Baleeiro said...

Any surprise that he had an unremarkable CT of chest less than a year ago?

Jeff H said...

Make it 3 for 3. Volume loss on the left with shift, suspicious for an endobronchial lesion. I'd do a CT scan to eval for lymphadenopathy, the bronch +/- Wang.

Baleeiro said...

I will post the CT and some f/up tomorrow to allow for more comments.

Mendez said...

No, not surprised. CT chest could easily miss bronchogenic CA, especially before the airways has become critically narrowed (leading to the obstruction and resultant findings).