Question

You are working in the ED at Harborview Medical Center. You are seeing a 52-year-old male patient who reports cough, fever, sweating, pleuritic chest pain and general malaise. Your examination reveals a fever of 102F, respiration rate 24bpm, rhonchi and decreased breath sounds, tachycardia with pulse of 116bpm, a tender one-inch mass on his right chest wall near his shoulder and right eye injection with reported pain and normal vision.
Your history indicates that he returned from Hawaii yesterday where he participated in the Ironman competition. He was seen in the ED in Kona, Hawaii two days earlier for similar symptoms that initiated 12 hours prior to that visit. He had an appendectomy and shoulder surgery in the past and reports episodic rashes over the past few months. He is married with adult children and works at the Fred Hutchinson Cancer Research Center in a molecular genetics laboratory with no patient care responsibilities. List two questions that you would ask the patient. For each, note your rationale (i.e. note why you think that question will help you diagnose this patients disease).

Answer 1

The symptoms mentioned in patient’s case history makes him a suspected case of Pancoast tumor. Although an accurate diagnosis can only be made after a complete set of clinical tests, we can get our suspicion of Pancoast tumor more firm by getting the following questions answered by the patient-

1. A Pancoast tumor is an apical tumor that is typically found in conjunction with a smoking history. The patient's smoking history, rapid and frequent onset of clinical signs such as cough, fever, sweating, pleuritic chest pain, general malaise and right eye injection with reported pain can suggest Pancoast tumor. Also, most of these symptoms are consistent with the onset of Pancoast syndrome and Horner's syndrome, which are a typical of patients with Pancoast tumor. Therefore, our first question to the patient would be about his smoking history (both primary and secondary smoking).

2. Our second would be about the family history of the patient, similar to all other cancer types persons with family history of lung cancer fall in suspect category of having Pancoast tumor.

Thanks!