September 2022 Pulmonary Case of the Month: A Sanguinary Case
Thursday, September 1, 2022 at 8:00AM Lewis J. Wesselius MD
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ USA
History of Present Illness
A 55 years-old woman presented to pulmonary clinic with shortness of breath and chest pain for 4-6 weeks. No specific timing for her symptoms or triggers. The symptoms occurring occasionally at random times. Her dyspnea was not limiting her daily activities, though she has been asking her partners to help with chores more than before. Her chest pain was sharp localized to left posterior chest wall that seldom get worse with taking a deep breath. At worse it’s mild. She also experienced dry cough that is occasional and not bothersome.
Past Medical History (PMH), Social History (SH), Family History (FH)
PMH
- Paraplegia secondary to gunshot wound to T11-12 in 2003; wheelchair-bound
- COVID 2021, incidentally diagnosed with no pulmonary symptoms
- Carpal tunnel syndrome, bilateral
- Acne
- GERD
- Splenectomy 2003 after uncontrolled bleeding from splenic laceration following gunshot wound
- Tubal ligation 2005
SH
- Former tobacco use, 15 pack-years, quit 2007
- Drinks alcohol twice weekly
- No illicit drug use
FH
- Markedly positive for cancer in parents, siblings, aunt and uncles
Medications
- Baclofen 15mg TID
- Gabapentin 600mg QID
- Ketoconazole 2% cream every other day
- Omeprazole 40mg QD
Physical examination
- Heart rate 78, respiratory rate 14, SpO2 97% on room air, blood pressure 130/82, weight 70 kg, BMI 23.5
- Respiratory: Clear breath sounds bilaterally. No crackles or wheezing. No clubbing
- Cardiovascular: normal S1, S2; no murmurs
- Abdominal: Soft, nontender. Normoactive bowel sounds
- Extremities: No edema, warm.
- Skin: No rashes.
- Neuro: Mood appropriate. Alert and oriented x 3. Paraplegia, wheelchair-bound.
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