Kelly Cawcutt, MD
Pritish Tosh, MD
Jennifer Elmer, RN, CNS
Scott Copeman, RRT
Christina Rivera, Pharm D, RPh
Division of Critical Care
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
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: 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.
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.
CBC: Hemoglobin 9.4 g/dL, white blood cell count 6,200 cells/mcL, platelet count 45,000/mcl
Lactate 1.8 mmol/L
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?
- Blood culture, sputum culture and urine culture
- Broad spectrum antibiotic coverage
- Intravenous fluids
- Urine culture
- 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