September 2016 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

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): 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 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

The patient is a 52 year-old woman with prior renal transplant in 1998 due to complications of pre-eclampsia. She had a recent decline in renal function leading to re-transplant on June 23 of this year. She was admitted to the hospital on July 8th with ventricular tachycardia. Treatment with amiodarone was begun with no further ventriuclar tachycardia. She is also taking usual anti-rejection medications.

Past Medical History, Social History and Family History

Other than the renal transplantation she has no other significant past medical history and has never smoked. Family history is noncontributory.

Physical Examination

Physical examination was unremarkable other than the surgical wounds associated with her renal transplants.

Radiography

Her chest x-ray is shown in Figure 1.

Figure 1. Admission chest radiograph.

What should be done at this time? (Click on the correct answer to proceed to the second of four panels)

1. Discontinue the amiodarone
2. Empiric antibiotics
3. Plasma brain naturetic peptide (BNP)
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. September 2016 pulmonary case of the month. Southwest J Pulm Crit Care. 2016;13(3):101-7. doi: http://dx.doi.org/10.13175/swjpcc086-16 PDF

March 2013 Pulmonary Case of the Month: Don’t Rein Me In

Robert W. Viggiano, MD

Michael B. Gotway, MD

Departments of Pulmonary Medicine and Radiology

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 70 year old man was referred for a pleural effusion. The patient had pitting edema of the lower extremities noted in March, 2013. At that time a myocardial perfusion study and an echocardiogram were interpreted as being normal with an ejection fraction of 55%. His primary care physician stopped the amlodipine he was taking for hypertension and his edema resolved. However, the amlodipine was restarted a few weeks later for blood pressure control.

PMH, SH, FH

He has a past medical history of hypertension and asthma. He was diagnosed with prostrate cancer in mid 2012. At that time a CT scan of his abdomen/pelvis and a MRI of his pelvis were negative for metastatic disease. He underwent robot assisted radical prostatectomy and bilateral pelvic lymph node dissection in August 2012. His final diagnosis was Gleason 4+5 disease present throughout the prostate with focal extraprostatic extension and lymphovascular and perineural invasion and invasion of right seminal vesicle. He was staged T 3B.

Present medications

• Amlodipine 5 mg at bedtime
• Omelsartan (Benicar®) 40 mg/day
• Salmeterol/fluticasone (Advair®) 100/50 1 puff twice a day
• Clonazepam 0.5 mg twice a day
• Lycopene 10 mg daily

He has a 10 year smoking history but no alcohol or drug use.

Family history is unremarkable.

Physical Examination

Vital signs: Normal

Lungs: Decreased breath sounds in both lung bases

Heart: Elevated JVP; Normal S1 and S2

Abdomen: Negative

Extremities: 2-3+ pitting edema

Laboratory

• CBC: normal
• Electrolytes: normal
• Serum creatinine: 1.0 mg/dL
• Total protein: 6.8 g/dL
• Albumin: 4.3 g/dL
• NT-pro brain naturetic peptide (BNP): 255 pg/ml

Radiography

Chest x-ray is shown in figure 1.

Figure 1. PA (panel A) and lateral (panel B) chest radiography.

Which of the following is false?

1. The patient’s chest x-ray shows bilateral pleural effusions right larger than left
2. A NT-pro BNP 255 pg/ml makes heart failure an unlikely diagnosis
3. His pleural effusion is most likely due to metastatic prostate cancer
4. A normal heart size on chest x-ray excludes heart failure
5. A normal echocardiogram excludes heart failure

Reference as: Viggiano RW, Gotway MB. March 2013 pulmonary case of the month: don't rein me in. Soutwest J Pulm Crit Care. 2013;6(3):93-102. PDF