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 

November 2015 Pulmonary Case of the Month

Kristal Choi, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 66 year-old woman was admitted to neurology with acute-onset dysarthria, right facial droop, and right-sided hemiparesis as a stroke alert. She also had a nonproductive cough and intermittent dyspnea for 4 months.

Past Medical History, Social History and Family History

• She has a history of hypertension and hyperlipidemia. 
• She smoked 1-2 packs/day for 15 years but quit 35 years ago. She drinks two glasses of wine per day.
• There is a family history of bowel and breast cancer.

Physical Examination

• Vital signs: T 36.8, HR 81, BP 129/75, RR 18, O2 sat 93% RA
• General: No acute distress. Awake and alert.
• Heart, abdomen, and lungs: No significant abnormalities
• Neurological: Mild right-sided nasolabial fold flattening.  Evidence of ptosis o the right eyelid. Hemiparesis on the right, the arm greater than leg. Sensation intact. Dysmetria on the right upper and lower extremities.

Laboratory Evaluation

• CBC: Hemoglobin 11.9 g/dL, white blood cells (WBC) 7,900 cells/mcL, platelets 290,000 cells/mcL
• Basic metabolic panel: Na+ 139 mEq/L, K+ 4 mEq/L, Cl- 100 mEq/L , bicarbonate 22 mEq/L, creatinine 0.7 mg/dL

Radiography

A head CT angiogram (CTA) was performed (Figure 1).

Figure 1. Representative images from CTA of the head.

Which of the following should be done next? (Click on the correct answer to proceed to the second of six panels)

1. Administer an intravenous injection of tissue plasminogen activator (TPA)
2. Administer detachable coils (coiling or endovascular embolization) or stereotactic radiosurgery
3. Begin an anti-convulsant and dexamethasone
4. 1 and 3
5. All of the above

Cite as: Choi K, Wesselius LW. November 2015 pulmonary case of the month. Southwest J Pulm Crit Care. 2015;11(5):200-8. doi: http://dx.doi.org/10.13175/swjpcc134-15 PDF

July 2014 Pulmonary Case of the Month: Where Did It Come From?

Colin B. Fitterer, MD

James M. Parish, MD

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 67 year old man presented with worsening cough and shortness of breath. He has a history of metastatic colon cancer first diagnosed in 2010. He was treated with radiation and chemotherapy (FOLFOX) but unfortunately developed new pulmonary nodules in October, 2013 which were metastatic colon cancer on biopsy. In February 2014 he developed a right parietal brain mass which was resected. Thoracic CT scan at that time showed progression of the pulmonary nodules. He has also noted a 30 pound weight loss over the past 6 months and an enlarging right supraclavicular lymph node.

PMH, FH, SH

In addition to the colon cancer, he has previous diagnoses of type 2 diabetes mellitus, hypertension, allergic rhinitis, and vitamin D deficiency. He is married and a recently retired railroad engineer. He has no history of tobacco use. There is a positive family history of lung cancer but no colon cancer.

Physical Examination

Vital Signs:  Temperature 36.8, pulse 98, respirations 18, blood pressure 144/70, SpO2 91% on 3 L via nasal cannula.

Pertinent findings include:

• A large firm and fixed right supraclavicular lymph node that is nonpainful on palpation.
• Diminished breath sounds across all right posterior lung fields with dullness to percussion. 
• Palpable liver edge is palpable approximately 2cm below the right costal margin.

Laboratory Analysis

Admission laboratory values include a hemoglobin of 11.1 g/dL but with a normal white blood cell count and platelet count. Electrolytes, blood urea nitrogen, creatinine, and liver enzymes were all within normal limits.  Serum chemistries are within normal limits.

Radiography

A chest x-ray (Figure 1A) and chest CT (Figure 1B) were performed.

Figure 1. Admission AP (Panel A) and representative image from the thoracic CT scan (Panel B).

Which of the following is the best interpretation of the radiographic findings? (Click on the correct answer to proceed to the next panel)

1. Large right pleural effusion
2. Right lung atelectasis
3. Right lung pneumonia
4. Right lung pulmonary edema
5. None of the above

Reference as: Fitterer CB, Parish JM. July 2014 pulmonary case of the month: where did it come from? Southwest J Pulm Crit Care. 2014;8(6):1-7. doi: http://dx.doi.org/10.13175/swjpcc080-14 PDF