Wednesday, May 31, 2006
'Just an update. I saw the new pulmo. doc and was very impressed. My pft's yesterday revealed a restrictive process that he felt was compatible with the neuromuscular disease. My dlco remains low. He's not sure why as he said that it doesn't necessarily fit in with the myopathy. He also was concerned with the high ANA and repeated that yesterday along with some other labs. He reviewed the ct chest and he noticed the enlarged lt atrium on the ct.When I go back to see him,he is going to repeat some more specific neuromuscular pft's.I told him what my cardiologist has said about not treating until the ef was < 30%. He did not feel comfortable with that as he felt that was too low to wait for treatment.Thank you for this great site.
Tuesday, May 30, 2006
My mother has bullous emphysema. i want to know how safe it is for her to fly commercial from tennessee to australia where i live for a visit. she was recently told that she might not be able to fly by a nurse. are there any special precautions she can take or things to do in this circumstance? I would really like to get her here for an extended visit if possible as she has not seen her youngest grandson yet.
This is a 60 y/o woman with a significant previous TOB Hx with very little on the way of symptoms. She had some cough and a CxR revealed a small nodule on the R. The CT scan below actually revealed two nodules, one on each side (see below, they are both fairly small). How concerned would you be and how would you work her up?
Friday, May 19, 2006
Thursday, May 18, 2006
Lung Ca (particularly adenos) can be receptor positice (I have seen a few references of over 25% positivity). Have you encountered a lot of these ER/PR+ lung Cas and does it have an impact on Tx?
Have you seen many endobronchial mets without parenchymal mets from other sites such as breast?
Wednesday, May 17, 2006
showed chronic and granulomatous inflammation, with focal active lung injury.
The BAL was negative for mycobacteria (specifically mycobacterium avium complex (MAC)). He was started on prednisone 60 mg and his symptoms are essentially resolved after 1 month of therapy. His followup CXR showed clearing of much of the prior acute interstitial infiltrates:
Final Diagnosis: Hypersensitivity pneumonitis ("Hot tub lung")
Tuesday, May 16, 2006
Many good suggestions were made to the role of inflammation in false-positive biopsies. I sent her to the chair of CT surgery at a nearby large university hospital and he was equally puzzled. While we were debating what to do, she developed new CHF, had a cath, PTCA, PM placed and and AICD. She has ischemic cardiomyopathy and was quite unstable to consider surgery right then and there. She was medically treated for her heart disease, stabilized and reassessed. Unfortunatelly, despite a negative PET three months before, on a repeat CT then PET she now had adenopathy and two small PET+ spinal mets... She was sent to oncologyand though the endoBBx looked like a squam it was poorly differentiated.
The oncologist requested staining for estrogen and progesterone receptos because of the Hx of breats Ca and those were positive.
A couple interesting questions came up.
Lung Ca (particularly adenos) can be receptor positice (I have seen a few references of over 25% positivity). With the receptor positivity would you automatically assume this is a breast Ca? Have you encountered a lot of these ER/PR+ lung Cas and does it have an impact on Tx?
If we regard that as a true late met of breast Ca, have you seen many endobronchial mets as in this case?
Monday, May 15, 2006
2. Benign prostatic hypertrophy.
4. Gastric reflux.
5. Osteoarthritis - What helps is etodolac 400 mg BID and soaking feet in hot tub.
Meds: Levoxyl, Protonix 40 mg daily, Plendil, terazosin, Atrovent, Advair, and Lodine 400 mg BID, Relpax PRN. For migraine headaches he used to take Cafergot
FHx - no lung or autoimmune disease
Shx - quit smoking 14 years ago after having smoked a pack per day for
35 to 40 years. Lives in a house which is new. He used to live in an apartment a few months ago with no problems there.
Spirometry: FEV1/FVC 68.5 (93%), FEV1 2.85 L (94%)FVC 4.16 L (101%)DLCO 54% predicted.
CPK normal 104, Sed. rate 15, ANA weakly positive, rheumatoid factor negative. He has had normal SPE, aldolase, cortisol, urinalysis, lytes-7 profile, liver profile, TSH, CBC. Cervical spine x-ray showed advanced degenerative changes. X-rays of the hands have shown osteoarthritis mainly at the first carpometacarpal joints. Lumbosacral spine x-ray showed degenerative changes.
Over the course of his progressive dyspnea he had some xray changes.
CXR last year:
During increased dyspnea:
What would you do next, or what thoughts do you have regarding the DDx?
Answer is here
Friday, May 12, 2006
A patient was just diagnosed with lung cancer and will be undergoing surgery soon. The tumor was discovered during an incidental Cxray and is approx 2.5 cm and located in the right lower lobe. We were encouraged to find that the ct scan showed no spread to the the lymph nodes and no pleural effusion. However, a subsequent PET scan showed bilateral Hilar uptake but no mediastinal uptake. The Thoracic surgeon scheduled a medianoscopy before the lobectomy just to make sure there was no spread of the cancer to the lymph nodes. His feeling is that the PET scan would have shown some mediastinal uptake on the PET scan and feels that the bilateral Hilar uptake is probably not cancer.
Just wanted to get some other views on this situation.
Thursday, May 11, 2006
How many passes do you make with the needle (presuming you do not have cytology at the bedside?
Tuesday, May 09, 2006
Monday, May 08, 2006
Have you seen many cases of OHV without OSA or structural lung disease?
Would you start her on BiPAP? If so would you try and get a titration study even though she does not meet OSA criteria? Otherwise how would you choose her settings?
Thursday, May 04, 2006
I am a41 yr old female dx'd with a probable mitochondrial myopathy. My muscle bx showed increased lipid drops. An EMG showed a myopathic trend. Testing for MG was negative. My pft's revealed fev1 77% of predicted, fev1/fvc 74%. Diffusing capacity at 69% of predicted- last one was 68%--DL/CO/VA of 5.45. MVV was 31% of predicted and negative inspiratory force was -10.
HRCT showed minimal bilateral basilar scarring vs interstitial changes. Echo showed left atrial enlargement,decreased lt ventricular systolic function,trace mitral and aortic regurgitation, ef of 45% (was >55% in 1999).
DO you think the decreased diffusion should be followed upon or is it because of the neuromuscular disease process going on? My pulmo said I have mild asthma but the muscle weakness is a bigger problem. Any suggestions would be appreciated.
Chest xray showed...normal except for degeneartive changes in the thoracic spine
My other PmHx is SF hashimoto&'s on synthroid. My ANA-1:640 speckled pattern
aldolase 7.1(1.2-7.6) ck 56.
Wednesday, May 03, 2006
We're selling our house, and the radon test came back at 3 pCi/L. The buyer suggested he wanted money to mitigate this level and we told him he could hold his breath for free.
Thought it would be interesting to get some discussion on radon and lung cancer risk. Why did the EPA choose 4 pCi/L as their action level? Is it reasonable to mitigate for a level of 3? I thought this was a good article to start with: Darby S. BMJ. 2005 Jan 29;330(7485):223.
Also, does anyone have any good articles on perception of risk or communicating risk?
Tuesday, May 02, 2006
"Associated Press - SANFORD, Fla. - A jury awarded $28 million Wednesday to a woman who sued her gynecologist for allegedly botching an operation that left her unable to urinate naturally."
"NORWALK, FL -- Norwalk Hospital, a former doctor and his practice have agreed to pay nearly $17 million to settle a lawsuit filed on behalf of a woman left in a vegetative state after giving birth."
"KIND OF PROCEEDING AND RULINGS IN CIRCUIT COURT
On February 13, 2003, petitioner [JKM], M.D., instituted the above-styled
action by filing a complaint pro se against respondents the West Virginia Trial Lawyers
Association and its then-President, William L. Frame." (from AAPSOnline).
Malpractice coverage and asset protection is becoming a bigger and bigger deal for physicians. What is the current status in your state? Is there a cap on "emotional suffering" damages? How friendly (or unfriendly) is your state towards physicians?
Monday, May 01, 2006
A chest xray at baseline is shown here:
A chest xray with the pain is shown here:
Based on that CXR, he was diagnosed with RUL pneumonia and prescribed a Z-Pak. His pain pertsisted. A month later a f/u chest CT was done. Other than severe upper lobe emphysema, the pertinent slice is shown here:
The 47 year old man with bilateral adenopathy who presented with hypercalcemia.
The 38 year old woman with seizures and multiple pulmonary nodules is still an unknown, so any additional comments would be appreciated.