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NBME 22 Answers

nbme22/Block 1/Question#31

A 60-year-old woman comes to the physician because ...

Lung cancer

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Weight loss - think cancer Hyponatremia - SIADH from small cell lung cancer Edema + JVD - SVC syndrome

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submitted by thirdaid(5),

The initial presentation looks like cancer: weight loss and progressive dyspnea over the course of months in a heavy smoker. Then, the question describes extra-pulmonary symptoms and a paraneoplastic syndrome.

More acutely, there is development of edema of the face and jugular venous distention. Because this is localized to upper body, we should think of a mechanical obstruction to venous flow as opposed to some cardiogenic reason. This is an extra-pulmonary symptom of lung cancer.

[ Superior Vena Cava Syndrome caused by the medial spreading of the tumor. Can be exacerbated in the physical exam by asking patient to raise both arms. ]

Finally, there is a single highlighted lab value -> hyponatremia. Small cell lung cancer can release inappropriate levels of antidiuretic hormone -> SIADH. ADH will retain water and decrease sodium concentration possibly leading to cerebral edema and seizures.

[ Syndrome of Inappropriate ADH (due to small cell carcinoma, a neuroendocrine tumor of the lung) decreases sodium concentration. Paraneoplastic syndrome. ]

In SketchyPath: SVC syndrome is the red balloon near the mediastinum ship and SIADH is the guy trying to carry the water cooler and getting water all over himself.

makinallkindzofgainz  I agree! Superior sulcus tumors is a lung carcinoma that occurs in the apex of the lung and can cause SVC syndrome. +