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  #1  
Old 05-23-2012
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Lungs Solitary pulmonary nodule

A 52-year-old woman is evaluated after an abdominal CT scan detected a 3-mm nodule in the
right lower pulmonary lobe. The CT scan was obtained to evaluate abdominal pain, which has
since completely resolved. The patient has never smoked. She works in the home and has
not been exposed to potential carcinogens. She has not had a chest radiograph or other
imaging procedure, except mammography. Her medical history is unremarkable, and she
takes no medication. Her family history is unremarkable.
The physical examination is normal.
Which of the following is the most appropriate next step in the management of this
patient?
(A) Chest radiograph in 3 months
(B) CT scan of the chest in 3 months
(C) CT scan of the chest in 6 months
(D) No follow-up
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  #2  
Old 05-23-2012
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read about it in kaplan LN but forgot........
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Old 05-23-2012
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I think it should be
radiograph in 3 months to check the change in the nature of SPN.
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Old 05-23-2012
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Answer is A
the ist step is to determine the risk status of the pt
then to order if there was any previous x ray done or not.
since this pt is low risk so we will follow up this pt with CXR in 3 months.
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Old 05-23-2012
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3mm is too small, and since there are no other risk factors except the age of the pt i will proceed with Ct after 6
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Old 05-23-2012
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Default the answer is B

ok the answer is B

here are the steps--
inital test--check for previous xray (but this option isnt there)

classify risk--- (pg 156 MTB 2)
1- age (>40)
2- smoking
3- size of nodule (>2cm)
4- calcifications
5- surrounding lung
6- border of nodule

based on this

LOW RISK--- follow up with serial CT scans every 3months for 2 years
MEDIUM risk-- BIOPSY either bronchoscopically or percutaneous/ Sputum
HIGH risk-- excision biopsy


this patients only risk factor is age. so its low risk
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  #7  
Old 05-23-2012
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ans is no follow upI thougjt she needs ct coz of her age

expl mainly says reason being her low risk

@bisho how we say its small vs large in spn

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Old 05-24-2012
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@Tyagee

classify risk--- (pg 156 MTB 2)
1- age (>40)
2- smoking
3- size of nodule (>2cm)
4- calcifications
5- surrounding lung
6- border of nodule

what is the question source ? qbank or other, cuz this is the explanation of UW & MTB is to follow with serial HRCT in low risk
look at table in mtb2 p156 this is the best u found to classify low, medium or high risk
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Old 05-24-2012
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Quote:
Originally Posted by bisho View Post
@Tyagee

classify risk--- (pg 156 MTB 2)
1- age (>40)
2- smoking
3- size of nodule (>2cm)
4- calcifications
5- surrounding lung
6- border of nodule

what is the question source ? qbank or other, cuz this is the explanation of UW & MTB is to follow with serial HRCT in low risk
look at table in mtb2 p156 this is the best u found to classify low, medium or high risk
I agree the answer should be Ct scan after 6months. Any new nodule in lungs should not be ignored. 3 months is a shorter duration I think, not sure though but its written 6 months in MTB.
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Old 05-24-2012
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Choice A --Automatically out since you cannot compare a CxR with a CT scan. The only reason they put in this choice there is to make people choose this as our brains are so programmed to choose CxR whenever the topic of "solitary pulmonary nodule" comes up.

Choices B & C --Not needed since it's less than 1 cm in a low risk patient.

Choice D--the right choice due to above reasons.
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Old 01-10-2013
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I don't believe a follow up via a CXR is the right answer. Quoting an AAFP article on Evaluation of the Solitary Pulmonary Nodule, "Chest radiographs should always be evaluated in multiple views to rule out false-positive findings, and all previous images should be reviewed to assess initial appearance of the nodule and doubling time. Chest radiography can potentially visualize nodules as small as 5 to 6 mm; however, this modality has a high false-negative rate" ---(emphasis on the 2nd sentence)

In this patient, a follow-up with a CT scan (Option B) might seem like the correct option but the following algorithm illustrates the mgmt of pxts with a solitary pulmonary nodule <8mm:





Adapted with permission from Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines. 2nd ed. Chest. 2007;132(3 suppl):120S.

Based on the pxt's age, I would repeat CT scan at 12 months; no further workup if no change.

But since this is not amongst any option, I think the questions assumes that she is a low-risk patient (no smoking hx, no symptoms, nodule is <5mm, no exposure to carcinogens, no family hx) even though she is above 40years of age; therefore the correct answer choice would be D (No-follow up)
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Internal-Medicine-, Pulmonology-, Step-2-Questions

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