A 45-year-old woman with no significant medical history presents to the clinic with progressive shortness of breath, dry cough, subjective fever, and chills for the last 4 weeks. Three weeks ago, she presented to the Emergency Department with the same complaints and a chest radiograph at that time revealed minimal consolidation in the left lower lobe. She was given a course of azithromycin, which failed to improve her symptoms. She has never smoked, usually runs 3 miles daily, and has been working as a secretary for the last 20 years. She has not traveled recently and has no sick contacts. On examination, her temperature is 37.6°C, blood pressure is 120/80 mmHg, and heart rate is 75 beats per minute. Cardiac examination is normal. Lung examination reveals scattered rales. Chest radiograph today reveals a consolidation in the right middle lobe.
What is the most likely diagnosis?
Cryptogenic organizing pneumonia. Cryptogenic organizing pneumonia (COP), also known as bronchiolitis obliterans organizing pneumonia (BOOP), often presents with subacute development of nonspecific constitutional symptoms including weight loss, fever, chills, and night sweats. Dyspnea and dry cough are also important historical features. (A) This subacute and progressive development of symptoms differentiates COP from CAP, which is often acute in presentation. Patients with COP have often been diagnosed with CAP in the past but fail to respond to treatment. Radiographic findings reveal “migrating” alveolar processes. (C, D) This patient has no exposure history to support silicosis or berylliosis as the diagnosis. (B) Idiopathic pulmonary fibrosis (IPF) typically presents with a more prolonged course than COP and radiographic findings show a reticulonodular/interstitial process.
A 68-year-old man with a history of hypertension and diabetes presents with fatigue and a 4.5-kg (10-lb) weight loss over the past 6 months. He denies hematochezia, melena, diarrhea, nausea, and vomiting. Laboratory findings reveal a hemoglobin level of 10.1 g/dL. Fecal occult blood test (FOBT) is positive.
Which of the following is the best next step in the management of this patient?
Colonoscopy. This patient is presenting with anemia (likely secondary to iron deficiency) and positive FOBT. Any older patient presenting with iron-deficiency anemia and positive FOBT must be evaluated with colonoscopy to determine if the underlying etiology is malignancy (colon cancer).
A 55-year-old woman presents to her primary care doctor complaining of shortness of breath, cough, and swelling of her face and right arm. Her medical history is significant for COPD, hypertension, and diabetes. She has an 80 pack-year smoking history. Physical examination reveals superficial venous engorgement over her chest with a plethoric face. Her right pupil is smaller than her left.
: Bronchogenic carcinoma. This patient has dyspnea, venous congestion in her face and arm, and Horner syndrome, which can all be explained by compression of nearby structures by lung cancer. This is called superior vena cava (SVC) syndrome, and is most often caused by bronchogenic carcinoma. (A) Pulmonary embolism would present with dyspnea, tachycardia, and positive risk factors for clotting (e.g., presence of a DVT). (B) Pancreatic cancer and other GI malignancies are associated with migratory thrombophlebitis; however, the rest of the symptoms/signs suggest SVC syndrome. (C) A COPD exacerbation would not present with superficial venous engorgement. (D) Anisocoria (difference in size between pupils) can be caused by any disruption is sympathetic or parasympathetic innervation to the pupil. A stroke would not fit the rest of this patient’s findings.
A 53-year-old woman with a history of nonischemic cardiomyopathy and paroxysmal atrial fibrillation presents to the Emergency Department with worsening shortness of breath for the last 3 days. She has also noticed increased swelling in her legs and decreased exercise tolerance. She used to do her grocery shopping for herself but now becomes too fatigued going to the grocery store and has her son do her shopping instead. She also reports intermittent diarrhea, palpitations, and sweating at night. Her laboratory values are shown below.
Which of her medications should be stopped?
Amiodarone. The patient described above is having an exacerbation of her heart failure, as evidenced by her worsening shortness of breath and leg swelling. One possible cause of this CHF exacerbation is hyperthyroidism, which is supported by her symptoms of diarrhea, palpitations, and night sweats, as well as her low TSH and elevated free T4 laboratory values. Of the listed medications, amiodarone is the only one that has the possibility of causing hyperthyroidism and should be discontinued. Amiodarone can also cause pulmonary fibrosis leading to shortness of breath.
A 24-year-old man presents for evaluation of a rash. Over the last 3 months, the rash has progressed from his scalp and face to his upper shoulders and back. The patient also endorses dandruff that has persisted even with the use of over-the-counter dandruff shampoo. The patient endorses pruritus but has no other complaints. Physical examination reveals erythematous plaques with greasy scale (Figure below).
Which of the following is the best next step in management of this patient?
HIV testing. This patient is presenting with the classic signs of seborrheic dermatitis. Erythematous plaques with greasy scale and indistinct margins describe seborrheic dermatitis. Seborrheic dermatitis is very common in HIV infection and can actually be the presenting feature. Up to 80% of HIV/AIDS patients have seborrheic dermatitis and these patients present with a greater severity. New onset of severe seborrheic dermatitis should prompt the practitioner to consider HIV infection.
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