April 2018 Pulmonary Case of the Month

Ashely L. Garrett, MD

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 74-year-old woman with known chronic obstructive pulmonary disease (COPD) presented to emergency department on 2/4/18 with dyspnea. She had been hospitalized at another hospital from 12/29/17 - 1/30/18 for a COPD exacerbation and health care associated pneumonia described as a cavitary pneumonia. She was treated with various doses of systemic steroids and antibiotics. Her course was complicated by atrial fibrillation with a rapid ventricular response. She eventually was discharged to a skilled nursing facility.

Past Medical History, Social History and Family History

She has a known history of COPD with an FEV1 of 22% of predicted and is on 2L/min of O2 by nasal cannula. There is also a history of:

• Hypertension.
• Hypercholesterolemia.
• Paroxysmal atrial fibrillation, not on anticoagulation.
• Right 4 mm PICA aneurysm

She lives in rural Kingman, AZ with some dust and outdoor bird exposure.

Family history is noncontributory.

Medications

• Alprazolam 0.25 mg p.o. b.i.d.
• Symbicort two puffs inhaled b.i.d.
• Diltiazem 120 mg p.o. q.12h
• Disopyramide 150 mg p.o. q.6h
• Furosemide 20 mg p.o. daily
• Levalbuterol 0.31 mg q.6 days p.r.n.
• Meperidine 50 mg p.r.n. pain
• Metoprolol succinate 12.5 mg p.o. b.i.d
• Prednisone 10 mg p.o. daily

Physical Examination

• Vitals: BP 110/65 mm Hg, P 130 irregular beats/min, T 37° C, Respirations 20 breaths/min
• General: Appears in mild respiratory distress
• Lungs: Distant breath sounds
• Heart: Irregular rhythm with distant tones
• Abdomen: no organomegaly, masses or tendernesses
• Extremities:  No edema

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

1. Arterial blood gases (ABGs)
2. Chest x-ray
3. Electrocardiogram
4. 1 and 3
5. All of the above

Cite as: Garrett AL. April 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(4):174-82. doi: https://doi.org/10.13175/swjpcc050-18 PDF

August 2015 Pulmonary Case of the Month: Holy Sheep

Jennifer M. Hall, DO

David M. Baratz, MD

Banner University Medical Center Phoenix

Phoenix, AZ

History of Present Illness

A 42-year-old woman presented to the emergency department with chest pain and dyspnea. The onset of symptoms was acute, initially endorsing left-sided sharp chest pain which then progressed with dyspnea. Chest radiograph was read as normal. Laboratory evaluation was notable for an elevated D-Dimer which prompted a thoracic CT scan to be obtained.

Past Medical History, Family History, Social History

• She had well-controlled rheumatoid arthritis (on no medical therapy) and was diagnosed with emphysema by her PCP two years earlier.
• Her mother died from pulmonary embolism secondary to underlying lung cancer.
• She quit smoking 2 years ago with a total of 20-pack-years.

Physical Examination

Patient was in mild distress with heart rate of 105, respiratory rate of 22, but otherwise stable, SpO2 was 95% while breathing ambient air. She had diminished breath sounds in both bases, but otherwise her chest was clear to auscultation. The remainder of the exam was unremarkable.

Radiography 

A chest x-ray (Figure 1) and a thoracic CT scan (Figure 2) were performed.

Figure 1. Initial PA of the chest.

Figure 2. Thoracic CT scan in lung windows. Panels A-F: representative static images. Lower panel: video.

A chest tube was placed for the left-sided pneumothorax.

What is the next step in management? (Click on the correct answer to proceed to the second of five panels)

1. Bronchoscopy
2. Consider pleurodesis
3. Observation with repeat CT in 3 months
4. Open lung biopsy
5. 1 and 3
6. 2 and 4

Reference as: Hall JM, Baratz DM. August 2015 pulmonary case of the month: holy sheep. Southwest J Pulm Crit Care. 2015;11(2):53-8. doi: http://dx.doi.org/10.13175/swjpcc103-15 PDF