A 70-year-old man presents with recurrent bilateral lower lobe pneumonia with mild dysphagia. On exam he is otherwise normal.
What is the procedure of choice to arrive at the diagnosis?
Correct Answer A:
Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration and airway obstruction.
Aspiration is the passage of food or liquid through the vocal folds. Persons who aspirate are at increased risk for the occurrence of serious respiratory sequelae, including airway obstruction and aspiration pneumonia.
The most valuable investigations in patients with suspected esophageal dysphagia include a barium swallow study, endoscopy and esophageal manometry. Diagnostic study of choice would be a barium swallow. The barium will show any structural defects such as strictures, narrowing or tumors.
A 60-year-old white male comes to your office for evaluation of a chronic cough productive of large amounts of sputum, accompanied by dyspnea on exertion. He has smoked 2 packs of cigarettes a day for the past 40 years.
The best diagnostic test for evaluating this problem is:
Correct Answer E:
Considering the patient's history, the most likely diagnosis is COPD. It is important to note that in questions that ask the single best answer, when two choices seem to be a possibility, then the most common is the right answer.
In patients with suspected COPD, the best diagnostic test is office spirometry (choice E). If the FEV1/FVC ratio is < 70% and the FEV1 is < 80% of predicted, the patient has COPD. This generally occurs in mid- to late life. While cigarette smoking is the largest single risk factor, only 20% of smokers develop clinically significant COPD. The second most common risk factor is alpha1-antitrypsin deficiency, which causes 1% of cases. These patients present with cough, sputum production, and dyspnea on exertion. They often experience orthopnea soon after reclining, whereas patients with heart failure typically experience orthopnea several hours after reclining, when fluid mobilizes from the lower extremities.
→ Arterial blood gases (choice A) would be the best test to evaluate the severity of an acute attack or exacerbation.
→ Alpha-1-antitrypsin(choice B) would be useful in patients with alpha1-antitrypsin deficiency. These patients develop COPD early even without exposure to tobacco products.
→ Brain natriuretic peptide (choice C) is useful in the assessment of patients with congestive heart failure. The most likely diagnosis in this patient is COPD.
→ CT of the chest (choice D) may be useful in the diagnosis of emphysema. However, it would only be used as an adjunctive study in a patient suspected of COPD.
A 42-year-old female presents with a 2-day history of chest pain. She describes the pain as sharp, located in the right upper chest, and worsened by deep breathing or coughing. She also complains of shortness of breath. She was previously healthy and has no recent history of travel. Her vital signs are normal. A pleural friction rub is noted on auscultation of the lungs. The remainder of the examination is normal. An EKG, cardiac enzymes, oxygen saturation, and a D-dimer level are all normal.
Which one of the following would be most appropriate at this point?
Correct Answer B:
This patient has pleurisy. Patients presenting with pleuritic chest pain may have life-threatening disorders, and pulmonary embolism, acute myocardial infarction, and pneumothorax should be excluded. While 5%-20% of patients with pulmonary embolism present with pleuritic chest pain, this patient has no risks for pulmonary embolism and the normal D-dimer level obviates the need for further evaluation. Moderate- to high-risk patients may need a helical CT scan or other diagnostic testing.
An EKG and chest radiograph are recommended in the evaluation of acute/subacute pleuritic chest pain. The chest radiograph will exclude pneumothorax, pleural effusion, or pneumonia. An echocardiogram would not be indicated if the cardiac examination and EKG are normal. An antinuclear antibody level could be considered in recurrent pleurisy or if other symptoms or signs of lupus were present, but it would not be indicated in this patient.
Most cases of acute pleurisy are viral and should be treated with NSAIDs unless the workup indicates another problem.
A 63-year-old man develops hemoptysis, weight loss and chest pain. His initial chest x-ray shows a mass which is further confirmed by CT of the chest. Biopsy is positive for malignancy.
Which of the following is least likely to be a cause of his lung cancer?
Correct Answer D:
Lung cancer is now the number one cause of cancer deaths in both men and women. Initial symptoms include hemoptysis, chest pain and weight loss. Imaging studies such as chest x-ray and chest CT are done. A bronchoscopy guided biopsy is needed to obtain a tissue sample to determine if the mass is malignant.
Smoking causes 87% of all lung cancers. Other causes include exposure to the following: asbestos, radon, arsenic, chromium, exposure to radiation, uranium, nickel, aromatic hydrocarbons and ethers.
Marijuana, unlike tobacco and alcohol, does not appear to cause head, neck, or lung cancer. The risk of lung cancer due to smoking marijuana or cocaine is less clear than with tobacco. An association between lung cancer and smoking these agents has been difficult to prove because studies were limited by selection bias, small sample size, and failure to adjust for tobacco smoking. In addition, the duration from the onset of drug use to outcome (ie, lung cancer) may have been too short for lung cancer to develop because young participants were enrolled in most studies.
A 72-year-old man with a history of recently diagnosed small cell cancer of the lung, presents to the emergency room following a witnessed, single, tonic-clonic seizure. His serum sodium is 106 mmol/L.
Which one of the following is the best immediate approach to the management of his electrolyte disturbance?
This patient most likely has severe syndrome of inappropriate antidiuretic hormone. Given the presentation, this patient should be treated with Intravenous 3% saline at 100 mL/hr with frequent (q 2 to 4 h) electrolyte determinations (choice E).
Severe hyponatremia (plasma Na < 109 mmol/L; effective osmolality < 238 mOsm/kg) in asymptomatic patients can be treated safely with stringent restriction of water intake. However, treatment is more aggressive when neurologic symptoms (eg, confusion, lethargy, seizures, coma) are present. The debate primarily concerns the pace and degree of hyponatremia correction.
Many experts recommend that plasma Na be raised no faster than 1 mmol/L/h, but replacement rates of up to 2 mmol/L/h for the first 2 to 3 h have been suggested for patients with seizures. Regardless, the rise should be ≤ 10 mmol/L over the first 24 h. More vigorous correction risks precipitation of osmotic demyelination syndrome.
Hypertonic (3%) saline (containing 513 mmol Na/L) may be used, but only with frequent (q 2 to 4 h) electrolyte determinations. For patients with seizures or coma, ≤ 100 mL/h may be administered over 4 to 6 h in amounts sufficient to raise the serum Na 4 to 6 mmol/L.
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