June 2020 Pulmonary Case of the Month: Twist and Shout

Lewis J. Wesselius, MD¹

Staci E. Beamer, MD² 

¹Departments of Pulmonary Medicine and ²Thoracic Surgery

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

An 83-year-old man presented with a left upper lobe lung nodule. The nodule was noted on a routine follow-up chest radiograph obtained after a radical cystectomy and left nephro-ureterectomy done 9 months earlier for invasive bladder cancer as well clear cell carcinoma of left kidney. He had symptoms of a mild chronic cough but denied shortness of breath with activities of daily living.

PMH, SH, FH

• Prostate cancer, post prostatectomy in 2009. 
• Bladder cancer and left renal cell cancer resected in Jan 2019
• Post-op chemotherapy after bladder and left kidney resections
• Non-ischemic cardiomyopathy, possibly due to            chemotherapy, EF 45%
• Chronic atrial fibrillation
• Smoking history: 60 pack years, no occupational exposures

Physical Examination

Other than an irregular pulse, his physical examination was unremarkable.

Medications

• Warfarin
• Atorvastatin
• Hydrochlorothiazide
• Ramipril
• Atenolol

Radiography

The initial chest radiograph is shown in Figure 1.

Figure 1. Initial chest x-ray.

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. Chest CT scan
2. Left upper lobectomy
3. Comparison to old chest x-rays
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ, Beamer SE. June 2020 pulmonary case of the month: twist and shout. Southwest J Pulm Crit Care. 2020;20(6):179-87. doi: https://doi.org/10.13175/swjpcc038-20 PDF 

March 2018 Pulmonary Case of the Month

Thomas D. Kummet, MD

Sequim, WA 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 panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Thomas D. Kummet, 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: University of Arizona College of Medicine at Banner University Medical Center Tucson

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

Financial Support Received: None

History of Present Illness

The patient was a 62-year-old woman who complained of a sudden severe increase in a three-month history of mild left upper extremity pain. 

PMH, SH and FH

The patient had no significant past medical history. She is a non-smoker. Family history is non-contributory.

Physical Examination

• Vital Signs: Pulse 102 beats/min, blood pressure 140/84 mm Hg, respirations 16 breaths/min, Temperature 37.4º C, SpO2 94% on room air.
• Lungs: Clear.
• Heart: Regular rhythm.
• Abdomen: without organomegaly, masses or tendernesses.
• Extremities: Both upper extremities were unremarkable. The left shoulder had a full range of motion. Pulses were intact bilaterally and equal.
• Neurologic: Upper extremity strength was good and equal. Light touch and pin prick were intact. Deep tendon reflexes were well preserved.

Which of the following are indicated in management at this time? (Click on the correct answer to proceed to the second of seven pages)

1. Reassurance that the pain will improve
2. Shoulder x-ray
3. Treatment with oxycodone
4. 1 and 3
5. All of the above

Cite as: Kummet TD. March 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(3):110-6. doi: https://doi.org/10.13175/swjpcc033-18 PDF