nyu medical grand rounds clinical vignette
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NYU Medical Grand Rounds Clinical Vignette. Karen Kan, MD Class of 2014 February 26, 2013. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. - PowerPoint PPT PresentationTRANSCRIPT
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NYU Medical Grand Rounds Clinical Vignette
Karen Kan, MD
Class of 2014
February 26, 2013
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• 49 year old non-smoking, Bangladeshi woman who presents with 3 years of dyspnea on exertion
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Lived on a rural farm in Bangladesh• Responsible for cooking and domestic chores• Dyspnea on exertion began 3 years prior to admission • Daily cough productive of clear sputum
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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History of Present Illness
• Dyspnea progressively worsened
• Limiting her exercise tolerance to “a few blocks”
• Her family brought her to the US and she subsequently presented to Bellevue Hospital
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Additional History
• Past Medical & Surgical History: None• Social History:
• No tobacco, alcohol or drug use• Originally from Bangladesh • Lived on a farm with no nearby factories• Worked indoors cooking for her family
• No family history of pulmonary disease• Home Medications: None• No Known Drug Allergies
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Physical Examination
• The patient was a well-appearing woman, in no acute distress
• Vital Signs: 98°F, BP 110/70, HR 60, RR 14 and oxygen saturation 97% on room air
• Her pulmonary exam was notable for mild bibasilar inspiratory crackles
• The remainder of the exam was normal
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Laboratory Findings
• Arterial blood gas on room air: pH 7.48, PaO2 88 mmHg, PaCO2 39 mmHg
• ESR 44 mm/hr (17 mm/hr)
• The CBC, BMP and hepatic panel were unremarkable
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Other Studies• Chest X-Ray
• Low lung volumes with scattered small nodules throughout all lung zones
• Chest CT
• Numerous 2-3 mm irregular nodules scattered throughout both lungs, sparing the pleural surface
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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Other Studies• Induced Sputums: Negative for AFB
• Pulmonary Function Tests:
• FVC 2.06L (80%), FEV1 1.72L (79%), FEV1/FVC 83%,
• FRC 2.88L (124%), TLC 3.84L (95%), RV 1.72L (117%)
• Diffusing capacity for CO 22.06 mL/min mmHg (130%)
• No response to bronchodilatorsUNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Chronic bronchitis from an environmental exposure
Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Patient remained in respiratory isolation until induced sputums were negative for AFB
• After imaging and spirometry were performed, she underwent bronchoscopy
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Bronchoscopy showed numerous dark plaques on the bronchus intermedius and the BAL was grossly gray in appearance and had a normal cell differential
• Transbronchial biopsy specimens showed anthracosis with thickening of the basement membrane
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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• Domestically Acquired Particulate Lung Disease (DAPLD) or “hut lung”
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS