Assignment:
A 17-year-old female presents to her local hospital's E.R. at 7:45 in the morning on a school day. She appears apprehensive and uncomfortable. She winces and splints her chest to the right side when she coughs. She is examined by the attending resident.
Patient History:
The patient appears apprehensive upon initial examination by the physician. The patient's first question of the attending physician is whether or not anything that she says, or that the physician finds out must be reported to her parents.
The patient is 17-years-old, and has been a smoker since the age of 12. Recently she has had a persistent cough that has not responded to O.T.C. cold medicine. This morning, as the student was getting ready for school she noticed that she was coughing up blood. Therefore, rather than driving to her high school she decided to come to the E.R. for an examination. She is quite concerned about the blood in her sputum and the possibility of lung cancer. In addition, she is quite concerned that her parents will find out that she is a smoker.
Physical Examination:
• Blood pressure is 125/75, and her pulse is 125.
• Cardiac sounds are normal at all ausculation points.
• Temperature is 104.3 F.
• Respiratory rate is 23/minute.
Height is 5'10", weight is 117 lbs.
The attending reassures the patient that preliminary tests will be run to potentially rule out the chances of cancer. The following preliminary tests are conducted, with the results noted:
• HEENT examination: normal
• Lungs: Inspection, palpation, percussion and ausculation of the lungs are normal expect for the following findings on the right lung:
o With the patient seated upright, ausculation reveals the following findings at the 2nd and 3rd intercostal spaces along the right midaxillary line: diminished vesicular breath sounds; enhanced bronchial breath sounds; increased intensity and clarity of spoken voice and whispered sounds; egophony; fine rales near the end of deep inspiration.
o Percussion dullness is found at the same sites.
• Cardiovascular examination: normal except for the tachycardia
• Abdomen: normal
• Genitourinary examination: normal
• Musculoskeletal examination: normal
• Neurological examination: normal
• Sputum examination: Mucous is yellowish and very thick, with streaks of bright-red blood.
• Throat swab: normal
PA and lateral chest films are ordered by the attending physician.
Questions
1. Identify some possible causes of blood in sputum.
2. Identify some possible causes of a persistent cough.
3. Identify the increased risk of lung cancer with exposure to smoking, and explain the physiological relationship between smoking, the alveolus and lung cancer.
4. Explain what a normal PA chest film would demonstrate, with particular reference to the structures that would be visible and their 3-dimensional anatomical relationships. Also describe what the lung fields of a normal individual would present.
5. Why did the physician order lateral chest films in addition to PA chest films?
6. Explain what a normal lateral chest film would demonstrate, with particular reference to the structures that would be visible and their 3-dimenstional anatomical relationships. Also describe what the lung fields of a normal individual would present.
7. What is a silhouette sign? Would this patient present one or more silhouette signs? Defend your answer.
8. What is your diagnosis of this patient? What test results would point towards this diagnosis?
9. What role might smoking have played in this patient's pathology?
10. What does the term aortic knob mean?