Lewis J. Wesselius, MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Pulmonary Case of the Month CME Information
Members of the Arizona, New Mexico and Colorado 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. The author(s)/contributor(s) state that they do not have any financial arrangements that could constitute a conflict of interest. Detailed Information
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- 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 the Arizona Health Sciences Center Credit Designation and Accreditation Statements.
Current Approval Period: January 7, 2013 - January 6, 2015
Original Release Date: November 1, 2013
Most Recent Review by Author: November 1, 2013
Most Recent Review by CME Sponsor: November 1, 2013
Financial Support Received: None
History of Present Illness
A 36 year old woman was referred to the pulmonary clinic at Mayo Clinic Arizona. In early May 2013 she developed headache and blurred vision. She was referred to a neuroopthalmologist who diagnosed a 6th cranial nerve palsy. She had a brain MRI and lumbar puncture (LP). Both were reported as normal. She was treated with corticosteroids and improved.
She was tapered off prednisone in late May and developed discomfort in her left ear with hearing loss and tinnitus. Some left facial asymmetry was noted.
She was treated with intra-tympanic steroid injections as well as oral steroids with some improvement. Her last dose of corticosteroids was 3 weeks prior to being seen.
At the beginning of August she developed speech and swallowing difficulties and was neurologically diagnosed with palsies in 4th, 6th, 8th, 9th, 10th and 11th cranial nerves. Other symptoms included photophobia and a non-productive cough. Two additional LPs were reported to be normal.
PMH, SH, FH
She had cervical cancer with a cone biopsy 2006 and right arthroscopic shoulder surgery. She is a nonsmoker who is a field engineer for a medical device company. She travels throughout the US extensively. There is no significant family history.
- Vitamin B and D
- Herbal remedy immunotox
On neurologic exam she had blurred vision with left gaze and facial asymmetry.
Otherwise, the physical exam was unremarkable.
Her complete blood count (CBC) and erythrocyte sedimentation rate (ESR) were within normal limits.
At this point which of the following are diagnostic tests that should be ordered?
- Anti-neutrophil cytoplasmic antibody (ANCA)
- Coccidiomycosis serology
- Lyme disease serology
- Serum angiotensin converting enzyme (ACE)
- All of the above