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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)

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
June 2012 Pulmonary Case of the Month:
   What’s a Millet Seed Look Like?
May 2012 Pulmonary Case of the Month:
   Things Are Not Always as They Seem
April 2012 Pulmonary Case of the Month:
   Could Have Fooled Me!

 

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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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

Tuesday
Oct012013

October 2013 Pulmonary Case of the Month: A Hidden Connection

Kelly Cawcutt, MD

Pritish Tosh, MD 

Jennifer Elmer, RN, CNS

Scott Copeman, RRT

Christina Rivera, Pharm D, RPh

 

Division of Critical Care

Mayo Clinic

Rochester, Minnesota

 

Pulmonary Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California 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): Kelly Cawcutt, 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: October 1, 2013

Most Recent Review by Author: October 1, 2013

Most Recent Review by CME Sponsor: October 1, 2013

Financial Support Received: None

History of Present Illness

A 58 year old woman, former smoker, presented to the pulmonary outpatient clinic at Mayo Clinic Rochester with dyspnea on exertion. In clinic, she was found to be tachycardic and febrile, and therefore, she was directly admitted to a medicine ward for possible sepsis.

She had progressive dyspnea on exertion, accompanied by symptoms of dry cough, muscle weakness, dry mouth, easy bruising and constipation without weight loss for approximately 9 months. During this time, she was also diagnosed with an idiopathic pulmonary embolus with initiation of warfarin.

PMH, SH, FH

During an extensive work-up for these symptoms she was found to have a Ca2+ channel antibody, with concern raised for possible paraneoplastic etiology, as positron emission tomography (PET) imaging also revealed abnormal uptake in lungs along with multiple lymph nodes, pancreatic tail, decreased cerebral metabolism suggestive of a diffuse encephalopathy and bilateral pulmonary infiltrates with cavitation in the lingula. She was also noted to have anemia and thrombocytopenia. Of note, she was up-to-date on all recommended cancer screenings.

Physical Examination

The patient was febrile (39°C), tachypneic (30 breaths/min) and tachycardic (110 beats/min) but blood pressure was normal (110/68 mm Hg). Otherwise physical examination was unremarkable.

Laboratory

CBC: Hemoglobin 9.4 g/dL, white blood cell count 6,200 cells/mcL, platelet count 45,000/mcl

Lactate 1.8 mmol/L

INR: 2.1

Radiography

Admission chest x-ray is shown in figure 1 and the PET scan obtained prior to admission in figure 2.

Figure 1. Admission chest x-ray.

 

Figure 2. Representative coronal images of the PET scan obtained prior to admission showing abnormal uptake in lungs along with multiple lymph nodes, pancreatic tail, decreased cerebral metabolism suggestive of a diffuse encephalopathy and bilateral pulmonary infiltrates with cavitation in the lingula. 

Which of the following should be done on admission?

  1. Blood culture, sputum culture and urine culture
  2. Broad spectrum antibiotic coverage
  3. Intravenous fluids
  4. Urine culture
  5. All of the above

Reference as: Cawcutt K, Tosh P, Elmer J, Copeman S, Rivera C. October 2013 pulmonary case of the month: a hidden connection. Southwest J Pulm Crit Care. 2013;7(4): . doi: http://dx.doi.org/10.13175/swjpcc108-13 PDF

Saturday
Sep142013

Bronchoscopic Cryoextraction: A Novel Approach for the Removal of Massive Endobronchial Blood Clots Causing Acute Airway Obstruction

Bhaskar Bhardwaj MBBS (bhaskar_bhardwaj@hotmail.com)1

Himanshu Bhardwaj MD (himanshu-bhardwaj@ouhsc.edu)2

Houssein A. Youness MD (houssain-youniss@ouhsc.edu)2

Ahmed Awab MD (ahmad-awab@ouhsc.edu)2

 

1Indira Gandhi Medical College, Department of Pulmonary Medicine and Tuberculosis,  Shimla, Himachal Pradesh, India

2Pulmonary Medicine & Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City. USA

 

Abstract

Acute airway obstruction due to large blood clots is known to cause life threatening hypoxemic respiratory failure which can be challenging to diagnose and manage. Different bronchoscopic modalities like rigid bronchoscopy, forceps, snares and catheters can be used to extract these obstructing blood clots but each of these different methods have their own limitations.  We describe a patient with iatrogenic endobronchial bleed with acute airway obstruction due to massive blood clot successfully managed using ‘cryoextraction’. This technique has been described as the treatment of choice for this clinical situation and this case highlights the fact that this technique can save patients from more aggressive invasive procedures. 

Introduction

Bronchoscopic cryoextraction using a cryoprobe is an infrequently used   therapeutic modality for the removal of tracheobronchial tree foreign bodies, especially those containing sufficient water or freezable liquid (1). This technique uses a liquid cryogen or coolant (usually nitrous oxide, nitrogen, or carbon dioxide) which is delivered under pressure to a specially designed cryoprobe that can be passed through the working channel of the flexible bronchoscope (2).  We present a case of acute life-threatening airway obstruction caused by large iatrogenic blood clots which was successfully managed using cryoextraction.

Case Report

A 54 years old male with history of renal transplant and chronic immune suppressive therapy was admitted to the intensive care unit with productive cough, fevers and dyspnea of 3 days duration. His initial vital signs showed blood pressure at 140/100 mm Hg, pulse 110, respiratory rate at 36, temperature 102 degree Fahrenheit and initial oxygen saturation of 70 % on supplemental nasal cannula oxygen at 4 liters/min.   Physical examination revealed diffuse bronchial breath sounds in the right lower lung fields and chest radiograph showed consolidation in the right lower lobe. (Figure 1).

Figure 1. Pre BAL chest radiograph showing right lower lobe consolidation consistent with pneumonia.

Arterial blood gas analysis was consistent with partial pressure of oxygen (PaO2) at 40 mm Hg. Patient remained hypoxic despite supplemental oxygen and eventually required endotracheal intubation with mechanical ventilation due to hypoxic respiratory failure. Patient was also started on empiric antibiotic therapy with ceftriaxone and azithromycin for severe community acquired pneumonia requiring intensive care unit care. Unfortunately, patient’s clinical condition deteriorated in next 48 hours despite continuous antibiotics. His oxygen requirements kept on escalating on mechanical ventilation besides continuous ongoing fever.

At this point, we decided to perform a bronchoscopy with a plan for bronchoalveolar lavage (BAL) given the high risk for atypical lung infections secondary to chronic immunosuppression in this patient. Airway examination during BAL showed extremely friable endobronchial mucosa with thick purulent secretions in the right lower lobe bronchi. Unfortunately, a massive endobronchial bleeding caused by an iatrogenic bronchial mucosal tear complicated the procedure. The most likely cause for this bleeding complication was bronchoscope induced mucosal trauma accentuated by vulnerability of the mucosal capillaries due to ongoing immunosuppression and pneumonia in this patient. BAL was terminated but patient became extremely hypoxic despite increasing fraction of inspired oxygen from initial 50% to 100%. Acute rise in peak airway pressures to 56 cm H2O were also noted. An urgent repeat chest radiograph showed worsening of right lower lobe consolidation with new atelectasis suggestive of an acute airway obstruction (Figure 2).

Figure 2.  Post BAL chest radiograph showing acutely worse right lower lobe infiltrates, consistent with atelectasis and acute airway obstruction due to massive blood clot.

Repeat flexible bronchoscopic exam showed a massive blood clot extending from right main stem bronchus to lower bronchi obstructing the bronchial lumen almost completely. Removal of blood clot was felt to be necessary to improve the hypoxia. Initial attempts to suction the endobronchial clots through flexible bronchoscope and forceps extraction were unsuccessful due to extremely friable nature of the fresh blood clot. We decided to use cryoextraction to remove the endobronchial clot emergently.

A flexible cryoprobe (ERBE cryotherapy system – 1.9 mm size cryoprobe) was extended through the working channel of the bronchoscope into the bronchi, was applied to the clot & frozen for 10 seconds. Frozen clot got firmly attached to the probe and it was successfully pulled out in one large piece (Figure 3).

Figure 3. Massive blood clot extracted from airways, attached to the cryoprobe.

This resulted in immediate improvement in patient’s oxygenation. Patient remained on mechanical ventilation and a repeat bronchoscopic airway examination next day did not show any further bleeding. A non-bleeding mucosal tear in the right main bronchus was identified as the possible source of initial bleed. Patient eventually improved with continued treatment; he was successfully extubated after one week of mechanical ventilatory support.  He was discharged home after total 2 weeks of hospitalization.   

Discussion

Acute airway obstruction due to endobronchial blood clots is an unusual, but not a rare event which can develop in variety of clinical settings like various pulmonary infections, bronchial carcinoma, intrathoracic trauma etc. Some of the common interventions reported to cause acute airway bleeding and subsequent bronchial obstruction due to blood clots include: Iatrogenic mucosal damage from suction catheter manipulation, bronchoalveolar lavage, transbronchial biopsy and tracheostomy placement (Table1) (3).

Clinical consequences of the acute bronchial obstruction can range from minimal impact on respiratory function to life threatening ventilator failure. Pertinent physical examination findings in these patients include decreased or absent breath sounds with occasional inspiratory or expiratory wheezing heard over the affected lobe or lung. Among mechanically ventilated patients, acute rise in peak inspiratory pressure (above 60 cm H2O) with decreased tidal volume are some other notable findings. One unusual presentation of massive endobronchial bleeding in mechanically ventilated patients occurs when the clot adheres to the distal end of the endobronchial tube resulting in ball-valve type obstruction. In this situation, the clot acts as one-way valve allowing only the inspiratory flow into the lower respiratory tract but blocking the expiratory flow. This mechanism can result in unilateral or bilateral lung hyperexpansion, thus increasing the risk of tension pneumothorax. Urgent endobronchial tube exchange in this situation can be lifesaving (3). The extent of hypoxemia due to endobronchial blood clot obstruction depends on the site, degree of obstruction and underlying condition of the lungs (3). Typical imaging findings include lobar or segmental atelectasis or air column cut-off of the trachea and main stem bronchi. The diagnosis is confirmed by direct visualization of the clot through flexible bronchoscope. Initial efforts targeted at the removal of the blood clot involve suctioning and grasping forceps extraction of the clot through a flexible bronchoscope. However, these methods often prove unsuccessful due to the friable structure of the blood clots. Moreover, suctioning through the flexible bronchoscope could pose a risk of re-bleeding. Other management options include rigid bronchoscopy, Fogarty catheter dislodgment of the clot and sometimes the use of topical thrombolytic agents with partial dissolution of clot aiding in suction removal of the clot in piecemeal fashion. Rigid bronchoscopy with clot extraction was used to be the treatment to choice for the management of acute obstructing endobronchial blood clots but it requires general anesthesia and may not be as readily available as needed for these acutely sick patients (4,5).

Cryoextraction using flexible cryoprobe is an underreported novel approach which can be successfully used in removal of large blood clots from the airways. One of the first descriptions of the use of cryoextraction in the removal of endobronchial blood clots was given by Mehta et al in one of their review about various interventions used in tracheobronchial foreign body extraction (6). This method allows freezing of the water component of the blood clots, leading to their removal in en-bloc. Additionally, freezing also has a hemostatic effect through vasoconstriction and rapid slowing of the circulation. Cryoextraction can also be used to extract mucus plugs and other foreign bodies containing some amount of freezable liquid. Under circumstances in which a foreign body does not have any or enough water content, one may consider spraying saline over the object and immediately freezing the foreign body; thus allowing successful cryoextraction. Freezing also leads to shrinking of the foreign objects, thereby easily separating them from inflamed mucosa and facilitating their removal. An additional advantage of this technique is the shorter learning curve needed to utilize the cryoprobe compared to the prolonged training required to master rigid bronchoscopy (7). One concern expressed about the cryoextraction of the massive endobronchial clots is that a large ‘frozen clot’ might be difficult to extract through the smaller sized endotracheal tubes and, if dislodged in that process, could lead to obstruction of the ET tube. 

Conclusion

Our case report illustrates the successful use of cryoextraction as a safe and cost effective tool which can be used in the quick removal of large airway clots causing symptomatic airway obstruction. This modality should be considered as the first line treatment in this clinical situation.1 Cryoextraction method can also spare patients from more invasive procedures like rigid bronchoscopy often used in these scenarios.6 In the absence of well-designed studies, this method must be objectively compared with other methods and more cases are needed to be analyzed in future studies.    

References

  1. Weerdt S, Noppen M, Remels L, et al. Successful removal of a massive endobronchial clot by means of cryotherapy. J Bronchol. 2005; 12:23-24. [CrossRef]
  2. Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? Clin Chest Med 2001; 22:319. [CrossRef]
  3. Arney KL, Judson MA, Sahn SA. Airway obstruction arising from blood clot: three reports and a review of the literature. Chest. 1999; 115(1):293-300. [CrossRef] [PubMed]
  4. Schummer W, Schummer C. Hemorrhagic Tracheobronchial obstruction. J Bronchol. 2001; 8(3):236. [CrossRef]
  5. Homasson JP, Vergnon JM .Cryotherapy to extract obstructing blood clots. J Bronchol 2002;9:158-9. [CrossRef]
  6. Mehta AC, Rafanan A. Extraction of airway foreign body in adults. J Bronchol. 2001; 8:123–131. [CrossRef]
  7. Rubio E, Gupta P, Ie S, Boyd M. Cryoextraction: a novel approach to remove aspirated chewing gum. Ann Thoracic Med. 2013; 8(1):58-59. [CrossRef] [PubMed]

Conflict of Interest disclosures: No financial or nonfinancial conflicts of interests exist for any of the involved authors.

Reference as: Bhardwaj B, Bhardwaj H, Youness HA, Awab A. Bronchoscopic cryoextraction: a novel approach for the removal of massive endobronchial blood clots causing acute airway obstruction. Southwest J Pulm Crit Care. 2013;7(3):184-9. doi: http://dx.doi.org/10.13175/swjpcc112-13 PDF 

 

Sunday
Sep012013

September 2013 Pulmonary Case of the Month: Chewing the Cud

Suresh Uppalapu, MD   

Manoj Mathew, MD 

Banner Good Samaritan Medical Center

Phoenix, AZ

 

History of Present Illness

A 30 year old Hispanic man presented to the emergency department (ED) after being involved in a motor vehicle accident. He was a restrained passenger and his car was hit from behind by another vehicle. His initial presenting complaints were chest and back pain. 

PMH, SH, FH

The patient was originally born in Sonora, Mexico but moved to the Phoenix area in 1998. However, he traveled to Mexico frequently.  He has no allergies and no significant past medical or surgical history.

His social habits include occasional alcohol consumption and a remote minimal smoking history. He denied illicit drug abuse. He was married and has 5 healthy children. He was working as a fork lift operator in a warehouse and was not taking any medications. A tuberculosis skin test and a human immunodeficiency virus (HIV) were negative 3 years ago when he applied for US Citizenship.

His parents are alive with hypertension and type 2 diabetes mellitus.

Physical Examination

His physical exam had normal vital signs and a Glasgow coma scale of 15. Physical exam showed clear lungs, normal heart sounds, and a benign abdominal exam. His neurological exam was normal.

Laboratory

His complete blood count (CBC) showed a white blood cell (WBC) count of 15.4 x 106 cells/mcL, hemoglobin of 11.8 g/dL, a hematocrit of 36 % and a normal platelet count. His basic metabolic profile and liver function chemistries were normal.

Radiography

His chest x-ray is shown in Figure 1.

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

 

Which of the following best describes the chest x-ray?

  1. A density in the right chest consistent with a fractured right mainstem bronchus
  2. An air-fluid level in the right chest consistent with a lung abcess
  3. Consolidation in the lateral right lung
  4. All of the above
  5. None of the above

Reference as: Uppalapu S, Mathew M. September 2013 pulmonary case of the month: chewing the cud. Southwest J Pulm Crit Care. 2013;7(3):135-41. http://dx.doi.org/10.13175/swjpcc103-13 PDF