September 2018 Pulmonary Case of the Month: Lung Cysts

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Pulmonary Case of the Month CME Information

Completion of an evaluation form is required to receive credit and a link is provided on the last page of the activity. 

0.50 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.50 hours

Lead Author(s): Lewis J. Wesselius, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives: As a result of completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: The University of Arizona College of Medicine-Tucson

Current Approval Period: January 1, 2017-December 31, 2018

Financial Support Received: None

History of Present Illness

A 67-year-old woman was referred for mild shortness of breath for several years, but worse since January 2018.  She has dyspnea on exertion after 1 block. An outside chest x-ray, electrocardiogram and echocardiogram are reported as normal. She was begun on prednisone at 40 mg/day and her symptoms improved. However, her symptoms worsened when the dose tapered to 5 mg/day. She gained 35 pounds while on the prednisone and tried a steroid inhaler therapy without benefit. She is still dyspneic after 1 block of exertion.

Past Medical History, Social History, Family History

• Her past medical history was only positive for gastroesophageal reflux for which she takes ranitidine and hypertension for which she takes lisinopril.
• She was a life-long nonsmoker.
• There was no occupational history, hot tub or bird exposures.
• Family history is noncontributory.

Physical Examination

• Her SpO2 was 94% on room air.
• Chest:  few crackles noted at right base.
• Cardiovascular: regular rate and rhythm without a murmur.
• Extremities: no edema or clubbing.

Which of the following should be done at this time? (Click on the correct answer to be directed to the second of eight pages)

1. Measure her SpO2 after exercise
2. Reassure the patient the patient that she has hysterical dyspnea
3. Pulmonary function testing
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2018 pulmonary case of the month: lung cysts. Southwest J Pulm Crit Care. 2018;17(3):85-92. doi: https://doi.org/10.13175/swjpcc101-18 PDF 

May 2016 Pulmonary Case of the Month

Jennifer M. Hall, DO

Banner University Medical Center Phoenix

Phoenix, AZ USA

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Jennifer M. Hall, DO.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

History of Present Illness

A 24-year-old woman was diagnosed with pneumonia while on her honeymoon in Europe. She received an unknown treatment as an outpatient. When she returned a repeat chest x-ray showed persistent lung infiltrates. At that time she was asymptomatic. She was referred to pulmonary for further evaluation.

Past Medical History, Family History, Social History

• Idiopathic thrombocytopenic purpura at age 8
• Recurrent “bronchitis” since childhood
• Lifelong non-smoker, occasional ETOH, no illicit drugs
• No significant family history, other than hypertension in her father

Physical Examination

She had bibasilar fine crackles (fine) otherwise her physical examination was unremarkable.

Radiography

A chest x-ray was performed and interpreted as showing bilateral basilar interstitial infiltrates (Figure 1).

Figure 1. Chest x-ray showing bibasilar interstitial infiltrates.

To better define the abnormalities on chest x-ray a thoracic CT scan was performed (Figure 2).

Figure 2. Representative images from the thoracic CT scan in lung windows.

Based on the CT scan, which of the following diagnosis is least likely? (Click on the correct answer to proceed to the second of five panels)

1. Hematogenous metastasis
2. Hypersensitivity pneumonitis
3. Lymphangitic metastasis
4. Miliary tuberculosis
5. Sarcoidosis

Cite as: Hall JM. May 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016 May;12(5):165-70. doi: http://dx.doi.org/10.13175/swjpcc037-16 PDF