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  #1  
Old 10-20-2011
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A 58-year-old man with poorly controlled emphysema comes to your office complaining of purplish striae in the abdomen, as well as a round appearance to his face, which he has noticed for the last 2 to 3 months. The patient has smoked two packs of cigarettes per day for the last 40 years and has recently noticed a change in the pattern of his cough, with grayish-brown sputum production. Other than his COPD he has suffered from no other medical problem. His blood pressure is 170/95 mm Hg in both arms, pulse is 100/min, respirations are 22/min, and temperature is 37.2 C (99 F). He has a rounded face, an excess deposit of fat over the dorsal part of the base of the neck, increased abdominal fat around the waist, and multiple purplish striae over the abdomen. After you review this patient’s clinical presentation and send blood for routine laboratory studies, which of the following is the most appropriate next diagnostic test?



A.

Overnight dexamethasone suppression test


B.

High-dose dexamethasone suppression test


C.

Electrocardiogram


D.

Chest radiograph


E.

CT scan of the abdomen
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  #2  
Old 10-20-2011
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According to the kaplan videos fisher said start with the high dose test

But everywwhere else states start with the low dose overnight dexa test
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Old 10-20-2011
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B. High-dose dexamethasone suppression test
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Old 10-20-2011
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The correct answer is D. This patient is presenting with symptoms compatible with Cushing's disease, a change in the pattern of his cough due to COPD, and new sputum production—all pointing toward a lung malignancy. He is a heavy smoker with an 80-pack-year history, which puts him at great risk of lung cancer. We know that one of the common paraneoplastic syndromes associated with small-cell lung cancer is production of ectopic ACTH by the tumor. So our first priority in this patient is to determine whether he has a lung mass, and the first step—which is quick, inexpensive, and of great diagnostic value—would be to perform a chest x-ray and see if a mass is visible.
Performing an overnight dexamethasone suppression test (choice A) would be the first step in proving the diagnosis of Cushing's syndrome; we are suspecting the cause of this patient’s symptoms to be secondary to an ectopic production of ACTH by a small-cell CA of the lung.
Performing a high-dose dexamethasone suppression test (choice B) is typically done once Cushing's syndrome is diagnosed. It can distinguish Cushing's disease (pitiutary adenoma) from adrenal tumors or ectopic ACTH production. Plasma ACTH can differentiate primary adrenal neoplasm from ectopic ACTH production.
Although an ECG (choice C) would be part of a routine workup, this test would not be of diagnostic value in this patient.
Performing a CT of the abdomen (choice E) is not appropriate as an initial study in this patient. An abdominal CT scan would be done if lung cancer is suspected by chest x-ray to look for possible metastasis to the adrenal or liver, which would reinforce our suspicion of a small-cell carcinoma of the lung which causes early metastasis to adrenals, liver, bone or brain.
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Old 10-21-2011
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When i was reading the question i was preety sure it was lung cancer as a cause but i still thought to go thru the full flow chart of
low dose abnormal

then 24 hour urine to confirm it really is abnormal and not a false +,

then high dose which would show non supression in his case as its not pituitary in origon

then acth which would be increased

and then finally CT chest.


EDIT : looking at all those steps now im thinking yeah it would have been better just to start out with the CXR when it is so obvious a lung cancer cause BUT i do hate questions like these in which there is a high degree of ambiguity cause sometimes the answer might be to go thry the proper method and sometimes its take the short cut.
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