Tuesday May 26th, approach to patient with chest pain, cavitary lesions

On Tuesday John gave me a fresh case that came in and we talked a bit about how to approach patients.

On internal medicine we see patients after they are referred. This is important because it helps us think about the two people we are working for. One is physician that consulted us - where we describe Reason for Referral (RFR for cool people). Next is the patient, who has a chief complaint, which may or may not be related to the reason for referral. Both of these issues should be addressed in our note.

Sometimes, we will not focus on a chief complaint if we feels its irrelevant, for example:

Chief complaint: "I ran out of animal crackers"

we probably don't need to pursue the details of this, but possibly pursue the route of psychosis.

John presented a male who had a history of chest pain: A discussion about the symptoms took place where we talked briefly about "must not miss diagnoses". So for example with chest pain

MI

Aortic dissection

Pneumothorax

PE

Esophageal rupture

Tamponade

Sucking chest wound is also life threatening

Although the above there own ways of presenting, have a low threshold for a CXR and ECG for all of the above when seeing patients in hospital as this will pick up the above the majority of the time (or at least make you suspicious of this).

In addition to thinking about life threatening causes/ "must not miss" diagnoses, it is also important to consider things that are not high yield, but we have cheap tests to pick them up, have good positive predictive value, and of course, change management.

For example, ordering an ecg in a patient with abdominal pain, although MI is low on the differential, it is possible, and if ECG were positive this would completely change our management of the patient.

Back to our patient, he came in with chest pain, some shortness of breath, fevers and chills, and was tachycardic when he presented. CTPA was initially ordered as chest x ray was quite unrevealing. Although the patient did not have a PE (and i think in this context this was a reasonable test to order), His Ct scan showed some peripheral cavitary lesions.

Approach to cavitating lesions is like most differentials

Infections: TB is the MUST NOT MISS (hence the patient was put on airborne precautions). Septic emboli from IE. Fungal infections.

Auto-immune: vasculitis, specifically Wegener’s

Malignancy: lung cancer or metastasis- usually metastasis is at the bases of the lungs as that’s where more blood flow is.

Congenital:

Mnemonic

·       C: cancer 

o   bronchogenic carcinoma: most frequently SCC

o   cavitatory pulmonary metastasis(es): again most frequently SCC

·       A: autoimmune; granulomas from 

o   Wegener's granulomatosis

o   rheumatoid arthritis (rheumatoid nodules) etc.

·       V: vascular (both bland and septic pulmonary embolus)

·       I: infection (bacterial/fungal)

o   pulmonary abscess

o   pulmonary tuberculosis

·       T: trauma - pneumatocoeles

·       Y: youth

o   CPAM

o   pulmonary sequestration

o   bronchogenic cyst

Here is a decent article on approach to cavitating lesions, it's a bit too lengthy but more as a decent resource as they REALLY go into details of infectious causes

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292573/