Jim is a talker, and a chain smoker. Jim has smoked cigarettes since he was in the army 50 years ago.
MUSL Health & Medical Lung Cancer Short Case Study
Lung Cancer Name: Please read the case report, define the words in RED and answer the questions at the end of the case.
Jim is a talker, and a chain smoker. Jim has smoked cigarettes since he was in the army 50 years ago. He smoked 2 packs a day for many years, but has worked his way to smoking just a pack a day. He loves to talk to anyone, usually with a cigarette animating his speech. His wife and kids have begged him to quit for years, but Jim assures them that he cannot quit. Besides, he really enjoys smoking. He smoked filter less cigarettes for many years, but switched to filtered to make the habit a bit healthier. Jim, now 74-years-old, was finding it difficult to do much at all and not become short of breath, so much so he was willing to go see a doctor. He presented with no significant past medical history other than the 3 weeks of worsening dyspnea on light exertion, chest pain, cough, and a 10 lb weight loss in 8 days. Just over 6 months ago, Jim was at his normal baseline state of health. Now he has had progressive worsening of his dyspnea on exertion (DOE) to where he cannot walk across a room or talk while sitting up without becoming short of breath; he has never had anything like this before. He rates his breathing troubles as a 7 of 10, with 10 being can’t breathe at all and 1 being normal. He says the breathing troubles are from his lungs/chest and not his nose/congestion. He has had the DOE for 6 month but progressive worsening in the last 3 weeks. He says the quality of his breathing is just “like suffocating” but he denies burning in his lungs or other feelings. He says that hot temperatures bring on his breathing troubles and coughing while cold temperatures will help relieve those symptoms. Additionally, Jim had a productive cough with whitish mucus that is not bloody or bilious, and often coughs so hard that he ends up vomiting; he has averaged vomiting once a day over the past few weeks. He has tried Mucinex which made his cough worse and Nyquil to help him get to sleep w/o coughing. He often experiences an aching/burning pain across his whole anterior chest, and sometimes he has more of a tightness in his chest. The chest pain is like bad heartburn. All of his symptoms have always occurred after eating and sometimes without a noticeable trigger. He has had no fevers, chills, or night sweats. He has no allergies, seasonal or otherwise, and no hx of breathing troubles/asthma. He reports feeling like he is wheezing, but no dyspnea at rest (as long as he is lying down), no orthopnea, and no paroxysmal nocturnal dyspnea. No hx of recurrent pneumonia. He has no sick contact, TB Please interpret the words in RED exposure (that he knows of – ie incarcerated, homeless). He also has no pets, has not been around any farm animals, and has not traveled recently or been around those who have. He has about an 84-pack year history with tobacco and has still smoked during the past three weeks despite the fact it will often bring about coughing symptoms. He does not have the CAD risks factors of Diabetes, HTN, or Hypercholesterolemia. There is no hx of cancers in his family, but while he’s never been diagnosed with asthma, his son does have this condition. He has worked as a car mechanic but does not seem to have any significant occupational risk factors (coal mining/worked around asbestos). Nine days earlier, Jim had gone to the ED with the same set of symptoms and had a CT Chest that showed a large right-sided mediastinal mass with “mass effect on the trachea and endobronchial extension as well as perihilar soft tissue lesion that was most concerning for a primary bronchogenic carcinoma.” Jim said at that time he wasn’t prepared to be an inpatient and stay overnight, so he signed out AMA. He had little to no change in his symptoms over the next 9 days and came to the ED again today. CT CHEST w/contrast IMPRESSION: 1. No CT evidence of acute pulmonary emboli. 2. Large mediastinal mass with mass effect on the trachea and endobronchial extension as well as perihilar soft tissue lesion is most concerning for a primary bronchogenic carcinoma. Tiny nodules in the right upper and lower lobes may represent tumor spread vs bronchial obstruction and mucus impaction.
Problem List: 1) LUNG MASS 2) DYSPNEA ON EXERTION 3) CHEST PAIN/ HEARTBURN/ TIGHTNESS 4) COUGHING/VOMITING 5) DECREASED PO INTAKE/WEIGHT LOSS 6) SMOKING Hx/NICOTINE ADDICTION 7) EtOH INTAKE Assess Jim’s situation
(Type in the cells of the table which will expand to accommodate your input)
1. What is your assessment of this situation:
2. What concerns would you have for Jim?
3. How would you advise Jim and his wife about the presence of a lung tumor? 4. How might this situation impact Jim’s family?
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