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Stump the Professor. J. Scott Neumeister Associate Professor Department of General Internal Medicine SWAN 2011. Dyspnea. A 72 year old Caucasian female presents in February with a 2 week history of feeling short of breath. Dyspnea. She states she had a sinus infection just

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    1. Stump the Professor J. Scott Neumeister Associate Professor Department of General Internal Medicine SWAN 2011

    2. Dyspnea A 72 year old Caucasian female presents in February with a 2 week history of feeling short of breath.

    3. Dyspnea She states she had a sinus infection just prior to the start of her dyspnea. She took antibiotics (Biaxin) which resolved her sinusitis. She notes she is short of breath with exertion particularly first thing in the morning.

    4. Dyspnea ROS: NO travel, cough, hemoptysis new meds fevers, weight loss chest pressure, palpitations orthopnea, pnd blood loss GI/GU sx Friend/family illness Furnace is also without complaints

    5. Dyspnea PMH Hodgkin’s lymphoma 1973. C4 subluxation. Osteoporosis. Back surgery 1995. Cataracts. GERD. Sinusitis NKMA MEDS Prilosec. Vit E. Calcium with Vit D. Annual Zoledronic acid infusions. Flexerilprn.

    6. Dyspnea SOC Married with 3 children. Lives in Atlantic,Iowa. (Farming community) No tob/etoh/drugs FAM Mom with stroke. Dad with MI, polycystic kidney disease, colon cancer.

    7. Dyspnea 130/80 90 16 37.2 Looks comfortable. Severe Kyphosis. Neck normal – no JVD or LN Faint wheezes upper lobes posteriorly RRR Abdomen normal with splenectomy scar (1973) Extremities look normal Neuro without focal findings

    8. 95% sat on room air. No change with a brief walk.

    9. Data CBC CMP all normal TSH D-dimer CPK Troponin CHF peptide EKG

    10. The patient states that she was evaluated by her home town physician and walked on a treadmill with normal EKG before and after walking.

    11. The patient was placed on steroids (40 mg a day) with an inhaler for ‘post viral bronchitis’ and reassured.

    12. With phone follow up 3 days later the patient was unable to talk. Her husband put her on the phone and she could only gasp for air. She was sent immediately to her local ER. Her O2 satswere normal. Upon arrival to see you (6 hours later due to ambulance issues) the patient was asymptomatic.

    13. The patient does not appear in any distress upon arrival. She states that she actually feels fine, now. With further questioning the patient states that this is typical – she is SOB in the morning when she gets up with resolution as the day progresses but when she goes to bed she gets SOB again. With further clarification the patient feels SOB mainly when she is recumbent.

    14. expiration inspiration

    15. Tracheal Sarcoma • 2% of head and neck tumors • Risk factors include Chemo, radiation, HIV, HHV 8, Genetic, and chronic irritation • Mixoid Chondrosarcoma survival 45% at 5 years • Chemotherapy generally not helpful • ? benefit from radiation

    16. Tracheal stenosis Tracheomalacia Tracheomalacia intubation Vocal cord paralysis Tumors Wegener’s Vocal cord polyps Adenopathy Tracheal tumor Relapsing Foreign body polychondritis

    17. Confusion A 56 year old male is brought in by his wife due to an abrupt onset of confusion.

    18. Confusion He had been well up until yesterday when he felt nauseated and had been vomiting. Hewas unable to keep down any oral intake.

    19. Confusion He looked cyanotic with a blood pressure of 90/52, heart rate of 130 and a saturation of 62%. He was subsequently intubated without getting any additional history

    20. PMH Adenocarcinoma of the Prostate (resection) Hypertension/Hyperlipidemia Splenectomy during peptic ulcer surgery Allergies Morphine Meds Lipitor, Celebrex, Toprol XL Social Computer systems Administrator. Has a cat for a pet. Family Dad with prostate CA

    21. Exam 93/72, 129, 38.4C Intubated and sedated. Head is atraumatic. Pupils normal. Throat normal. No LN No JVD. Carotids normal. Tachycardic but no murmur or rub. Lungs clear. Abdomen soft with normal bowel sounds. Extremities no longer look cyanotic. No focal on neuro but he is sedated.

    22. Data WBC 7.6 Na+ 137 Hgb 15.7 K+ 4.4 Plt 97 Cl- 102 Bands 26% HCO3 17 BUN 37 D-dimer4Cr 2.9 PT 23.3 Gluc30 INR 2.0 Ca+ 8.7 PTT 57.4 CK 140 PSA 0.1TropNormal

    23. CXR – atelectasis Spiral CT – No PE EKG- sinus tachycardia DIC screen positive Lactic acid elevated ADAMTS13 negative

    24. His wife states that he went hunting 1 week ago. No tic bites No blood splatter Bitten by one of the hunting dogs

    25. Blood culture revealed gram negative rods in 3 of 3 bottles (aerobic and anaerobic) On day 3 the organism was identified…..

    26. Capnocytophaga Canimorsus • 5 million animal bites in the US each year • Dog bites 85%, Cat bites 10% • 20 deaths per year from animal bites • 8- 14 years of age most common group • Asplenic/Alcoholic/Glucocorticoids • DIC/Shock/Meningitis/Endocarditis/Arthritis • Incubation 1 – 30 days (Avg. 5 days) • Beta Lactamase Inhibitor/Clinda/Quinolone

    27. Cough A 51 year old Caucasian female complains of a 2 month history of coughing

    28. Cough 4 weeks ago she felt feverish but this has resolved. She has had a persistent cough with purulent sputum production. There is not a time of day where it is better or worse.

    29. Cough No: SOB Chest pain Orthopnea/pnd Travel Exposure Sinus trouble GERD New meds Weight loss Edema

    30. Cough She has noted a tremor that has worsened over the past year. Her Metoprolol makes it a little better. She does not have any gait difficulties (pain due to OA of her knee) No other family members have a tremor.

    31. Cough/Tremor PMH: Hypertension ,Diabetes Essential tremor, Osteoarthritis knees Tibial Plateau fracture, Appy, Tubal SOC: No tobacco. 2-3 drinks/day. No drugs Works at a fast food restaurant. Single. 1 son. FM: Mom with COPD, CVA. DAD with CAD

    32. Cough/Tremor Meds: Lopressor 100 mg BID Glucotrol XL 20mg Norvasc 5mg Glucophage 1gm bid Lisinopril 20 mg Avandia 4mg HCTZ 25 mg

    33. Exam: 140/90, 90, 37.5, 22 Sinuses non tender. Pharynx clear. Heart RRR. No murmur or JVD Lungs CTA and percussion Abdomen normal bowel sounds, no organomegally Extremities are without edema Subtle intention tremor in her hands

    34. CBC, CMP, COAGS are normal A1c was 7.0

    35. Posterior Mediastinal Mass

    36. A biopsy confirmed a malignancy consistent with a Carcinoid tumor. The patient was referred to Oncology then to Thoracic surgery for resection.

    37. During resection, she had profound low blood pressures (no bleeding). She recovered with fluids and a brief course of pressors. All of her blood pressure and diabetes meds were stopped. On follow up there was no indication to restart her meds. Her tremor had also resolved

    38. Normetanephrines 3x upper limit of normal

    39. Intrathoracic Paravertebral Paraganglionoma • Posterior mediastinal Tumor • 90% benign • Can have neurohormonal properties similar to Pheochromocytoma • Arise from intercostal nerves or sympathetic chain • Biopsies are often misleading (25%)

    40. Mediastinal Tumors • Posterior • Anterior • Superior • Middle Neurogenic, Esophageal, Bone, Aneurysms Thymus, Thyroid, Teratoma, Lymphoma, Pericardial cyst Thyroid, Aneurysms, Esophageal, Neurogenic Bronchogenic carcinoma, Lymphoma, Aneurysms, Cysts