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Pulmonary

Last 50 Pulmonary Postings

(Click on title to be directed to posting, most recent listed first, CME offerings in Bold)

Systemic Lupus Erythematosus Presenting As Cryptogenic Organizing 
   Pneumonia: Case Report
February 2015 Pulmonary Case of the Month: Severe Asthma
January 2015 Pulmonary Case of the Month: More Red Wine, Every
   Time
December 2014 Pulmonary Case of the Month: Bronchiolitis in Adults
November 2014 Pulmonary Case of the Month: BAL Eosinophilia
How Does Genetics Influence Valley Fever? Research Underway Now To
   Answer This Question
October 2014 Pulmonary Case of the Month: A Big Clot
September 2014 Pulmonary Case of the Month: A Case for Biblical
   Scholars
Role of Endobronchial Ultrasound in the Diagnosis and Management of
Bronchogenic Cysts: Two Case Descriptions and Literature Review
Azathioprine Associated Acute Respiratory Distress Syndrome: Case Report
   and Literature Review
August 2014 Pulmonary Case of the Month: A Physician's Job is 
   Never Done
July 2014 Pulmonary Case of the Month: Where Did It Come From?
June 2014 Pulmonary Case of the Month: "Petrified"
May 2014 Pulmonary Case of the Month: Stress Relief
Giant Cell Myocarditis: A Case Report and Review of the Literature
April 2014 Pulmonary Case of the Month: DIP-What?
Wireless Capsule Endo Bronchoscopy
Elevated Tumor Markers In Coccidioidomycosis of the Female Genital Tract
March 2014 Pulmonary Case of the Month: The Cure May Be Worse
   Than the Disease
February 2014 Pulmonary Case of the Month: Faster Is Not Always
   Better
January 2014 Pulmonary Case of the Month: Too Much, Too Late
32 Year Old Man with “Community-Acquired” Pneumonia
December 2013 Pulmonary Case of the Month: Natural
   Progression
November 2013 Pulmonary Case of the Month: Dalmatian Lungs
October 2013 Pulmonary Case of the Month: A Hidden Connection
Bronchoscopic Cryoextraction: A Novel Approach for the Removal
   of Massive Endobronchial Blood Clots Causing Acute Airway
   Obstruction
September 2013 Pulmonary Case of the Month: Chewing the Cud
IgG4-Related Systemic Disease of the Pancreas with Involvement 
   of the Lung: A Case Report and Literature Review
August 2013 Pulmonary Case of the Month: Aids for Diagnosis
Variation in Southwestern Hospital Charges for Pulmonary
   and Critical Care DRGs
July 2013 Pulmonary Case of the Month: Swan Song
June 2013 Pulmonary Case of the Month: Diagnosis
   Makes a Difference
May 2013 Pulmonary Case of the Month: the Cure Can be
   Worse than the Disease
April 2013 Pulmonary Case of the Month: 
   A Suffocating Relationship
Doxycycline Decreases Production of Interleukin-8
in A549 Human Lung Epithelial Cells
March 2013 Pulmonary Case of the Month:
   Don’t Rein Me In
February 2013 Pulmonary Case of the Month: 
   One Thing Leads to Another
January 2013 Pulmonary Case of the Month:
   Maybe We Should Call GI
December 2012 Pulmonary Case of the Month: Applying Genetics
November 2012 Pulmonary Case of the Month:
   The Wolves Are at the Door
October 2012 Pulmonary Case of the Month: 
Hemoptysis from an Uncommon Cause
Acetylcholine Stimulation of Human Neutrophil Chemotactic 
   Activity Is Directly Inhibited by Tiotropium Involving Gq Protein
   and ERK-1/2 Regulation
September 2012 Pulmonary Case of the Month:
The War on Drugs
Tiotropium Bromide Inhibits Human Monocyte Chemotaxis 
August 2012 Pulmonary Case of the Month:
   All Eosinophilia Is Not Asthma
COPD Exacerbations: An Evidence-Based Review
July 2012 Pulmonary Case of the Month: Pulmonary Infiltrates -
   Getting to the Heart of the Problem
Cough and Pleural Disease in a Burmese Immigrant – A Masquerader
Meta-Analysis of Self-Management Education for Patients with 
   Chronic Obstructive Pulmonary Disease

 

For complete pulmonary listings click here.

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.

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Wednesday
Jan012014

January 2014 Pulmonary Case of the Month: Too Much, Too Late

Chidinma Chima-Okereke MD  

Department of Pulmonary Medicine

Cedars Sinai Medical Center

Los Angeles, CA

 

Chief Complaint: Difficulty breathing

History of Present Illness

A 49-year-old gentleman with history of hepatitis C cirrhosis complicated by ascites presented to the emergency room of Olive View Medical Center in San Fernando Valley, California complaining of worsening shortness of breath. The patient reports that he occasionally has shortness of breath, usually about 2-3 times a year. However for the past 2 months, he has had worsening dyspnea on exertion and cannot walk further than 5 minutes. He also reports orthopnea and paroxysmal nocturnal dyspnea. He has been having a dry cough for the past 3-4 weeks.

He has a history of chronic ascites that has required multiple taps. He has been taking his prescribed diuretics however instead of taking these medications daily he takes them about every other day due to financial constraints.

However, his abdominal distention and his lower extremity swelling are stable. He reports some nausea with decreased appetite. He also has a new symptom of left-sided chest pain that radiates down his left arm and shoulder that lasts about 20 minutes and has no associated symptoms. .

He denies any fevers or chills or weight change. He has no sick contacts.

Past Medical and Surgical History

  • Hepatitis C cirrhosis
  • Chronic lower extremity edema
  • Ascites, status post multiple large volume paracentesis
  • History of chronic abdominal pain treated with morphine
  • Status post chest tube when he was a 17-year-old due to a gunshot wound

Social History

  • History of incarceration, released about 8 months ago
  • 6-pack of beer a day – quit 12 years ago.
  • Former smoker, quit 10 years ago, 7 pack-years
  • IV heroin use 15 years ago
  • No cocaine, amphetamines or any inhaled substances
  • No recent travel, occupational, pet or bird exposures
  • Lives with his fiancé in Lancaster, California

Family History

  • Father died of an MI at age 56.
  • Mother - SLE, DM, Stroke
  • Sister - Colon cancer
  • Brother - Hepatitis C cirrhosis

Medications

  • Controlled-release morphine sulfate 15 mg p.o. every morning and 30 mg p.o. every evening.
  • Furosemide 40 mg p.o. daily.
  • Spironolactone 50 mg p.o. daily.
  • Lactulose 15 mL p.o. b.i.d. p.r.n.

Review of Systems

Positive for pleuritic chest pain, night sweats, chills, dry cough - unproductive of sputum, lightening and darkening of urine, lower extremity edema, palpitations, decreased appetite, dry mouth, joint stiffness in the morning.    

Physical Examination

  • Vital signs: T 97.4 BP 115/67, HR 89, RR 20, SpO2 93%/RA
  • Lung exam was significant for bilateral crackles midway up the back.
  • Abdominal exam was non-tender and not suggestive of ascites
  • Lower extremities: 1+ bilateral pitting edema up to the knees.
  • Multiple skin tattoos and erythema in his lower extremities  
  • Muscle strength was 3/5 in the lower extremities, 4/5 in upper extremities bilaterally.
  • Otherwise the physical exam was unremarkable.

Laboratory

  • Basic Metabolic Panel was within normal limits.
  • Complete blood count (CBC): White count 6.3 X 103/mm3 with 8.3% eosinophils, hemoglobin 12.3 g/dL, platelets 130,000/µL.
  • Liver function tests (LFTs): AST 78 IU/L, ALT 42 IU/L, alkaline phosphatase 115, total bilirubin 1.3 mg/dL, INR 1.3, albumin 2.7 g/dL.
  • Brain naturetic peptide (BNP) 38 ng/L, troponin is 0.008 ng/ml.

Radiography

A chest x-ray was obtained (Figure 1).

Figure 1. Admission AP (Panel A) and lateral (Panel B) chest x-ray.

The chest x-ray was interpreted as poor inspiration with elevation of the right diaphragm. The heart is at least upper limits of normal in size. Pulmonary vessels are congested. The azygos vein is mildly dilated. No significant pleural effusion is detected in these two views.

A CT angiogram was obtained to rule out pulmonary embolism (Figure 2).

Figure 2. Panels A-D: Representative static axial images from the thoracic CT scan lung windows. Lower panel: movie of representative axial thoracic CT scan lung windows.

Hospital Course

He was admitted to the medicine wards, diuresed with furosemide 40 mg IV, spironolactone 100 mg by mouth and fluid restricted.

At this point which of the following are diagnostic tests that should be ordered? (click on correct answer to move to next panel)

  1. Coccidiomycosis serology
  2. HIV
  3. Quantiferon TB and sputum AFB
  4. Rheumatologic work up including anti-neutrophil cytoplasmic antibody (ANCA), ANA and subtypes, RA and anticentromere antibodies
  5. All of the above

Reference as: Chima-Okereke C. January 2014 pulmonary case of the month: too much, too late. Southwest J Pulm Crit Care. 2013;8(1):4-17. doi: http://dx.doi.org/10.13175/swjpcc162-13 PDF

Wednesday
Dec252013

32 Year Old Man with “Community-Acquired” Pneumonia

Jill K. Gersh, M.D., MPH1, Michelle K. Haas MD2,3,4

1Department of Medicine, University of Colorado Denver, Aurora, CO; 2Denver Health Medical Center, Denver, CO; 3Denver Metro Tuberculosis Clinic, Denver, CO; 4Division of Infectious Diseases, Department of Medicine, University of Colorado Denver, Aurora, CO

Corresponding author: Jill Gersh, M.D., MPH Phone: 303-602-5052 Fax: 303-602-5055. Email: JILL.GERSH@UCDENVER.EDU

All authors declare they have no conflicts of interest to disclose.

 

Abstract

Background: Community-acquired pneumonia is a common reason for hospital admission; however underlying pathogens vary depending on host immunity and circulating pathogens in the community.

Case Summary: A 32 year old man from Malawi presented with community-acquired pneumonia. After failing outpatient management, he was admitted and found to have underlying HIV disease. His diagnostic work up was initially inconclusive for M. tuberculosis (TB) and thus his diagnostic evaluation and treatment focused on other etiologies. He was ultimately diagnosed with TB after an invasive procedure and had a rapid clinical response after initiating TB treatment.

Conclusion: Both failure to recognize that TB can present with a syndrome similar to bacterial pneumonia and over-reliance on diagnostic testing delayed the diagnosis of TB. Delays in diagnosis contributed to substantial morbidity and risked nosocomial transmission.  Despite declining incidence in the US, providers should remain cognizant of diagnostic limitations for TB disease and have a low threshold for empiric treatment.

Introduction

Community-acquired pneumonia (CAP) is a common reason for presentation to care. The epidemiology of CAP can vary depending on the patient’s community of origin and underlying co-morbidities (1). We present a case of a 32 year old man who presented with CAP in whom his diagnosis was delayed due to failure to fully consider these factors.  

Case

A 32 year old man from Malawi[1] presented to the emergency department (ED) with cough and dyspnea that failed to respond to a 5 day course of azithromycin. Chest radiography (CXR) was performed (Figure 1), demonstrating right middle lobe consolidation with ipsilateral hilar lymphadenopathy (LAD).

Figure 1. PA view of the chest demonstrating right middle lobe consolidation and ipsilateral hilar lymphadenopathy at the time of his first ED presentation and approximately 10 days into his illness.

He was diagnosed with CAP and discharged with a 7 day course of amoxicillin-clavulanate. His symptoms progressed with fevers, and weight loss.  He presented for the second time to the ED and repeat CXR showed worsening right-sided hilar LAD and right middle lobe consolidation (Figure 2).

Figure 2. PA view of the chest demonstrating worsening of right middle lobe consolidation and right sided hilar lymphadenopathy at the time of admission to the hospital and approximately 17 days into his illness.

A rapid HIV test was positive and his CD4 count was 60 cells/µL. He was admitted and started on ceftriaxone, azithromycin and trimethoprim-sulfamethoxazole daily. He was placed on respiratory isolation and three sputum samples for acid-fast bacilli (AFB) smear and culture were collected, all of which were AFB smear negative. He then underwent bronchoscopy and his bronchoalveolar lavage smear was negative for AFB. His tuberculin skin test (TST) was negative as was an interferon gamma release assay (IGRA). He was then removed from respiratory isolation.

He continued to worsen with daily fevers as high as 43ºC while antimicrobial coverage was broadened to vancomycin and cefepime. He eventually underwent mediastinoscopy and lymph node (LN) biopsy. The following day LN tissue was positive for AFB and probe identified Mycobacterium tuberculosis (TB). Twenty-nine days after his initial presentation and 15 days into his hospitalization he was started on anti-tuberculosis therapy with isoniazid, rifampin, pyrazinamide and ethambutol. His cough improved within 2 days, his fevers were gone by day 4 and he was discharged. All sputum cultures grew TB. Antiretroviral therapy was initiated five weeks into his TB treatment. He had an excellent clinical and radiographic response (Figure 3) and completed 9 months of TB treatment.

Figure 3. PA view of the chest after 9 months of treatment for M. tuberculosis. Noted here is resolution of right sided hilar lymphadenopathy and resolution of his right middle lobe consolidation with some residual scarring noted. Sputum culture converted at 2 months.

Diagnosis: Pulmonary tuberculosis.

Discussion

TB is the leading cause of death among HIV-infected individuals globally and the leading cause of morbidity in HIV-infected individuals (2). TB can present as an acute pneumonia with rapid progression of disease including sepsis and respiratory failure. Cough may not be a prominent feature and may be of less than two weeks duration. Additional signs and symptoms include fevers, night sweats, weight loss, hepatosplenomegaly, and lymphadenopathy. Individuals with CD4 counts < 100 cells/µL are more likely to present with disseminated disease and less likely to have cavitary disease. HIV-infected patients are also more likely to present with AFB smear negative disease even when severely ill (3). Chest radiograph findings vary from normal appearing films to hilar lymphadenopathy, diffuse infiltrates, and lobar consolidation.

TST and IGRAs are often negative and serve as poor screening tools for active disease. Up to 25% of individuals may have a negative TST or IGRA while having active disease, particularly HIV-infected individuals with advanced immunodeficiency (4). A negative result should never lower the clinical suspicion for active TB.

Delays in TB treatment are a major contributor to excess mortality in HIV-infected patients (2). The importance of early empiric treatment in HIV-infected individuals cannot be overstated. The World Health Organization (WHO) published guidelines in 2007 for the management of HIV-infected individuals suspected of having TB (5). While WHO guidelines are developed for low resource settings, these guidelines have relevance in the U.S. when managing patients with HIV who have lived or traveled to areas with a high burden of TB. 

The failure to recognize that his clinical syndrome of CAP included TB as the underlying pathogen led to delayed treatment, prolonged hospitalization and risked nosocomial transmission. One unintended consequence of the success of our TB control programs may be the growing lack of clinical experience with TB among our providers. More broadly, how much of what we do as U.S. healthcare providers is because we can, and instead of what we should? Imagine if he couldn't get a mediastinoscopy and biopsy. Is it possible that his treatment course would have been improved by a lack of these resources?  We would do well to learn from our colleagues practicing in resource limited settings where prescribing empiric TB treatment and assessing for a clinical response is standard of care. In this patient’s case, less really would have been more.

References

  1. Nyamande K, Lalloo UG, John M. TB presenting as community-acquired pneumonia in a setting of high TB incidence and high HIV prevalence. Int J Tuberc Lung Dis. 2007;11(12):1308-13. [PubMed] 
  2. Wong EB, Omar T, Setlhako GJ, et al. Causes of death on antiretroviral therapy: a post-mortem study from South Africa. PloS one. 2012;7(10):e47542. [CrossRef] [PubMed]
  3. Elliott AM, Halwiindi B, Hayes RJ, Luo N, Tembo G, Machiels L, Bem C, Steenbergen G, Pobee JO, Nunn PP, et al. The impact of human immunodeficiency virus on presentation and diagnosis of tuberculosis in a cohort study in Zambia. J Trop Med Hyg. 1993;96(1):1-11. [PubMed] 
  4. Cattamanchi A, Ssewenyana I, Davis JL, Huang L, Worodria W, den Boon S, Yoo S, Andama A, Hopewell PC, Cao H. Role of interferon-gamma release assays in the diagnosis of pulmonary tuberculosis in patients with advanced HIV infection. BMC Infect Dis. 2010;10:75. [CrossRef] [PubMed]
  5. Improving the diagnosis and treatment of smear-negative pulmonary and extrapulmonary tuberculosis among adults and adolescents: recommendations for HIV-prevelent and resource constrained settings. Geneva: World Health Organization;2007.

Acknowledgements

The authors wish to thank Carolyn Welch, MD for her thoughtful review of this case report.

Reference as: Gersh JK, Haas MK. 32 year old man with "community-acquired' pneumonia. Southwest J Pulm Crit Care. 2013;7(6):355-9. doi: http://dx.doi.org/10.13175/swjpcc173-13 PDF

 

Sunday
Dec012013

December 2013 Pulmonary Case of the Month: Natural Progression

Robert W. Viggiano, MD 

 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

 

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): Robert W. Viggiano, MD. The author(s)/contributor(s) state that they do not have any financial arrangements that could constitute a conflict of interest. Detailed Information

Learning Objectives:
As a result of this activity I will be better able to:

  1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
  2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
  3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
  4. 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: December 1, 2013

Most Recent Review by Author: December 1, 2013

Most Recent Review by CME Sponsor: December 1, 2013

Financial Support Received: None

 

History of Present Illness

A 68 year old woman was seen for increased back pain in April 2012. In 2000 she had a right lower lobe lung resection for low grade adenocarcinoma, bronchoalveolar type, nonmucinous. Her mass was 2.6 cm in maximal dimension extending to but not invading the pleura. There were clear surgical margins but involvement of one bronchial node. Multiple mediastinal nodes were negative. She had back pain for many years and yearly CTs were negative for metastatic disease.

PMH, SH, FH

Other than the above there was no significant past medical history, social history or family history.

Medications

  • Non-steroidal anti-inflammatory drugs for pain 
  • Nitrofurantoin for chronic urinary tract infections

Physical Examination

There was tenderness to palpation over the mid-thoracic spine and evidence of a previous thoracotomy.

Laboratory

Her complete blood count (CBC), urinanalysis, liver function tests, and calcium were all within normal limits.

Radiology

An x-ray of the chest is interpreted as unchanged from previous x-rays. 

At this point which of the following radiologic testing is not indicated? (click on correct answer to move to next panel)

  1. Bone scan
  2. CT scan of the chest
  3. Magnetic resonance imaging
  4. Serial chest x-rays
  5. Thoracic PET scan

Reference as: Viggiano RW. December 2013 pulmonary case of the month: natural progression. Southwest J Pulm Crit Care. 2013;7(6):318-27. doi: http://dx.doi.org/10.13175/swjpcc155-13 PDF

Sunday
Dec012013

December 2013 Pulmonary Case of the Month: Natural Progression

Robert W. Viggiano, MD

 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

 

History of Present Illness

A 68 year old woman was seen for increased back pain in April 2012. In 2000 she had a right lower lobe lung resection for low grade adenocarcinoma, bronchoalveolar type, nonmucinous. Her mass was 2.6 cm in maximal dimension extending to but not invading the pleura. There were clear surgical margins but involvement of one bronchial node. Multiple mediastinal nodes were negative. She had back pain for many years and yearly CTs were negative for metastatic disease.

PMH, SH, FH

Other than the above there was no significant past medical history, social history or family history.

Medications

  • Non-steroidal anti-inflammatory drugs for pain
  • Nitrofurantoin for chronic urinary tract infections

Physical Examination

There was tenderness to palpation over the mid-thoracic spine and evidence of a previous thoracotomy.

Laboratory

Her complete blood count (CBC), urinanalysis, liver function tests, and calcium were all within normal limits.

Radiology

An x-ray of the chest is interpreted as unchanged from previous x-rays. 

At this point which of the following radiologic testing is not indicated?

  1. Bone scan
  2. CT scan of the chest
  3. Magnetic resonance imaging
  4. Serial chest x-rays
  5. Thoracic PET scan

Reference as: Viggiano RW. December 2013 pulmonary case of the month: natural progression. Southwest J Pulm Crit Care. 2013;7(6): . doi: http://dx.doi.org/10.13175/swjpcc155-13 PDF

Friday
Nov012013

November 2013 Pulmonary Case of the Month: Dalmatian Lungs

Lewis J. Wesselius, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

 

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

Learning Objectives:
As a result of this activity I will be better able to:

  1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
  2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
  3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
  4. 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.

Medications

  • Zolpidem 
  • Vitamin B and D
  • Herbal remedy immunotox

Physical Examination

On neurologic exam she had blurred vision with left gaze and facial asymmetry.

Otherwise, the physical exam was unremarkable.

Laboratory

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?

  1. Anti-neutrophil cytoplasmic antibody (ANCA)
  2. Coccidiomycosis serology
  3. Lyme disease serology
  4. Serum angiotensin converting enzyme (ACE)
  5. All of the above

Reference as: Wesselius LJ. November 2013 pulmonary case of the month: dalmatian lungs. Southwest J Pulm Crit Care. 2013;7(5):271-8. doi: http://dx.doi.org/10.13175/swjpcc130-13 PDF

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