Pulmonary
The Southwest Journal of Pulmonary and Critical Care publishes articles broadly related to pulmonary medicine including thoracic surgery, transplantation, airways disease, pediatric pulmonology, anesthesiolgy, pharmacology, nursing and more. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.
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?
- The patient’s chest x-ray shows bilateral pleural effusions right larger than left
- A NT-pro BNP 255 pg/ml makes heart failure an unlikely diagnosis
- His pleural effusion is most likely due to metastatic prostate cancer
- A normal heart size on chest x-ray excludes heart failure
- 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