PULMONOLOGY VIGNETTES Q AND A
LaryngealbuCancerbu-buanswer--CommonbuVignette
Abu57-year-oldbumanbupresentsbuwithbuabu6-
monthbuhistorybuofbuhoarseness.buHebuhasbuabureactivebuairwaybudiseasebudiagnosisbuandb
uisbutreatedbuforbuasthma.buOverbuthebulastbuweekbuhebuhasbunotedbuprogressivebudifficultybu
breathing.buHebualsobuhasbuotalgia,budysphagia,buodynophagiabu(painfulbuswallowing),bua
ndbuabu9-kgbuweightbuloss.buHebuhasbuanbu80-pack-
yearbutobaccobuhistorybuandbudrinksbu8bubeersbuperbuday.buOnbuphysicalbuexam,buoralbucavi
tybuandbuoropharynxbuarebuwithinbunormalbulimits.buNeckbuexambudemonstratesbuaburight-
sidedbumassbuthatbuisbufirmbuandbufixed.buCranialbunervebuexambuisbunormal.buTherebuisbumil
dbubiphasicbustridorbuwithbudeepbuinspirationbuandbuexpiration,bubutbuthebupatientbuhasbunobu
increasedbuworkbuofbubreathingbuatburest,buandbubreathbusoundsbuarebuclear.buFlexiblebufibe
ropticbularyngoscopybudemonstratesbuabunecrotic,buulceratingbumassbuinvolvingbutheburigh
tbutruebuandbufalsebuvocalbucords,buandbuextensionbuontobuthebuepiglottisbuandbuaryepiglotti
cbufolds.buTheburightbutruebuvocalbucordbuisbuimmobile.buThebuglotticbuairwaybuisbupartiallybuo
bstructed.
LaryngealbuCancerbu-buanswer--CommonbuVignette
Abu45-year-oldbumanbupresentsbuwithbuabu3-
monthbuhistorybuofbusorebuthroatbuandbupainless,buenlarging,buleft-
sidedbuneckbumass.buTwobucoursesbuofbuantibioticsbuandbuabutrialbuofbucorticosteroidsbudidbu
notbuclearbuthebusorebuthroatbuandbumass.buHebualsobureportsbudysphagiabuwithbusolidsbuan
dbuworseningbuodynophagiabu(painfulbuswallowing),buandbuabu7-
kgbuweightbulossbuoverbuthebulastbu2bumonths.buHisbupastbumedicalbuhistorybuisbusignificantbu
forbuhypertensionbuandbuCOPD,bubothbuwellbucontrolledbuwithbumedication.buHebuhasbuabu5
0-pack-yearbusmokingbuhistory.buPhysicalbuexambufindsbuabu2-
cm,bufirm,bumobile,buandbunontenderbumassbuanteriorbutobuthebusternocleidomastoidbumus
clebuinbuthebupatient'sbumidbuleftbucervicalbulymphbunodebuchain.buTherebuisbunobuoverlyingbu
erythemabuorbuinduration.buThebuoralbucavitybuandbuoropharynxbuarebunormal,buasbuarebuth
ebucranialbunervesbuonbuexam.buBreathbusoundsbuarebuclearbuwithoutbustridorbuorbustertor.bu
Flexiblebufiberopticbularyngoscopybudemonstratesbuabuthickenedbuepiglottisbuwithbuanbuulc
eratingbuandbunecroticbumassbuonbuitsbularyngealbusurfacebuthatbuextendsbutobuinvolvebubot
hbuaryepiglotticbufoldsbuandbuthebuleftbutruebuandbufalsebuvocalbucords.buThebutruebuvocalbuco
rdsbuarebumobilebubilaterallybuandbuappearbunormal.
Non-SmallbuCellbuLungbuCancerbu-buanswer--CommonbuVignette
Abu65-year-oldbumanbupresentsbuwithbuabu2-
monthbuhistorybuofbuabudrybupersistentbucoughbuandbu4.5bukgbuunintentionalbuweightbuloss.bu
Hebudeniesbufevers,budyspnea,busorebuthroat,burhinorrhea,buchestbupain,buorbuhemoptysis.b
uMedicalbuhistorybuisbusignificantbuforbuCOPDbuandbuhypertension.buFamilybuhistorybuisbuno
ncontributory.buHebusmokedbu1bupackbuofbucigarettesbudailybuforbu40buyearsbubutbuquitbu5buy
earsbuago.buNobuadenopathybuisbupalpablebuonbuexaminationbuandbubreathbusoundsbuarebu
diminishedbugloballybuwithoutbufocalbuwheezesbuorburales.
PulmonarybuEmbolismbu-buanswer--CommonbuVignette
, Abu65-year-
oldbumanbupresentsbutobuthebuemergencybudepartmentbuwithbuacutebuonsetbuofbuSOBbuofbu3
0buminutes'buduration.buInitially,buhebufeltbufaintbubutbudidbunotbulosebuconsciousness.buHebui
sbucomplainingbuofbuleft-
sidedbuchestbupainbuthatbuworsensbuonbudeepbuinspiration.buHebuhasbunobuhistorybuofbucardi
opulmonarybudisease.buAbuweekbuagobuhebuunderwentbuabutotalbuleftbuhipbureplacementbua
nd,bufollowingbudischarge,buwasbuonbubedburestbuforbu3budaysbuduebutobupoorlybucontrolledbu
pain.buHebusubsequentlybunoticedbuswellingbuinbuhisbuleftbucalf,buwhichbuisbutenderbuonbuexa
mination.buHisbucurrentbuvitalbusignsburevealbuabufeverbuofbu100.4°Fbu(38.0°C),buheartburateb
u112bubpm,buBPbu95/65bummHg,buandbuanbuO2busaturationbuonburoombuairbuofbu91%.
PulmonarybuArterybuHypertensionbu-buanswer--CommonbuVignette
Abu36-year-oldbuwomanbupresentsbuwithbuabu6-
monthbuhistorybuofbugraduallybuprogressivebudyspneabuonbuexertionbuandbufatigue.buOnbup
hysicalbuexam,buherbuvitalbusignsbuarebunormalbuandbushebuappearsbunotbutobubebuinbuanybudi
stress.buHerbulungsbuarebuclearbutobuauscultation.buHerbucardiacbuexambushowsbuabupromin
entbujugularbuVbuwave,buanbuaccentuatedbupulmonicbucomponentbutobuthebusecondbuheartbu
soundbu(P2),buandbuabuhigh-
pitchedbuholosystolicbumurmurbubestbuheardbuatbuthebuleftbusternalbuborder.
AcutebuBronchitisbu-buanswer--CommonbuVignette
Abu34-year-oldbuwomanbuwithbunobuknownbuunderlyingbulungbudiseasebuhasbuhadbuabu12-
daybuhistorybuofbucoughbuthatbuhasbubecomebuproductivebuofbusputum.buInitiallybushebuwasb
unotbushortbuofbubreath,bubutbunowbushebubecomesbushortbuofbubreathbuwithbuexertion.buSheb
uinitiallybuhadbunasalbucongestionbuandbuabumildbusorebuthroat,bubutbunowbuherbusymptomsbu
arebuallburelatedbutobuabuproductivebucoughbuwithoutbuparoxysms.buShebudeniesbuanybusickb
ucontacts.buOnbuphysicalbuexaminationbushebuisbunotbuinburespiratorybudistressbuandbuisbuaf
ebrilebuwithbunormalbuvitalbusigns.buNobusignsbuofbuURIbuarebunoted.buScatteredbuwheezesbu
arebupresentbudiffuselybuonbulungbuauscultation.
CommunitybuAcquiredbuPneumoniabu-buanswer--CommonbuVignette
Abu54-year-
oldbusmokerbuwithbumultiplebucomorbiditiesbu(diabetes,buhypertension,bucoronarybuarterybu
disease)bupresentsbuwithbuabu2-
daybuhistorybuofbuabuproductivebucoughbuwithbuyellowbusputum,buchestbutightness,buandbufe
ver.buPhysicalbuexamburevealsbuabutemperaturebuofbu101°Fbu(38.3°C),buBPbuofbu150/95bum
mHg,buheartburatebuofbu85bubpm,buandbuaburespiratoryburatebuofbu20bubreathsbuperbuminute.bu
Hisbuoxygenbusaturationbuisbu95%buatburest;bulungbusoundsbuarebudistantbubutbuclear,buwithbu
cracklesbuatbuthebuleftbubase.buCXRburevealsbuabuleftbulowerbulobebuinfiltrate.
HospitalbuAcquiredbuPneumoniabu-buanswer--CommonbuVignettebu
Abu55-year-
oldbumanbuwithbuabuhistorybuofbuperipheralbuvascularbudisease,buwhobupresentsbuwithbuabuco
mplaintbuofbuabuleftbufootbuulcerbuandbupainbuwhenbuwalkingbushortbudistances,buisbufoundbut
obuhavebuabupoplitealbustenosisbuandbuadmittedbuforburevascularization.buFourbudaysbuafter
buadmission,buonbupostoperativebudaybu3,buhebudevelopsbuSOB,buhypoxia,buandbuabuproduc
tivebucough.buAuscultationbuofbuhisbuchestburevealsbudecreasedbubreathbusoundsbuatbuthebul
owerbuaspectbuofbutheburightbusidebuofbuhisbuchest.buHisbumorningbuleukocytebucountbuisbuslig
htlybuhigherbuthanbuthebudaybubefore,buatbu11,000bucells/mL^3.buAnbuanterior-
posteriorbubedsidebuCXRburevealsburightbulowerbulobebuopacity.
LaryngealbuCancerbu-buanswer--CommonbuVignette
Abu57-year-oldbumanbupresentsbuwithbuabu6-
monthbuhistorybuofbuhoarseness.buHebuhasbuabureactivebuairwaybudiseasebudiagnosisbuandb
uisbutreatedbuforbuasthma.buOverbuthebulastbuweekbuhebuhasbunotedbuprogressivebudifficultybu
breathing.buHebualsobuhasbuotalgia,budysphagia,buodynophagiabu(painfulbuswallowing),bua
ndbuabu9-kgbuweightbuloss.buHebuhasbuanbu80-pack-
yearbutobaccobuhistorybuandbudrinksbu8bubeersbuperbuday.buOnbuphysicalbuexam,buoralbucavi
tybuandbuoropharynxbuarebuwithinbunormalbulimits.buNeckbuexambudemonstratesbuaburight-
sidedbumassbuthatbuisbufirmbuandbufixed.buCranialbunervebuexambuisbunormal.buTherebuisbumil
dbubiphasicbustridorbuwithbudeepbuinspirationbuandbuexpiration,bubutbuthebupatientbuhasbunobu
increasedbuworkbuofbubreathingbuatburest,buandbubreathbusoundsbuarebuclear.buFlexiblebufibe
ropticbularyngoscopybudemonstratesbuabunecrotic,buulceratingbumassbuinvolvingbutheburigh
tbutruebuandbufalsebuvocalbucords,buandbuextensionbuontobuthebuepiglottisbuandbuaryepiglotti
cbufolds.buTheburightbutruebuvocalbucordbuisbuimmobile.buThebuglotticbuairwaybuisbupartiallybuo
bstructed.
LaryngealbuCancerbu-buanswer--CommonbuVignette
Abu45-year-oldbumanbupresentsbuwithbuabu3-
monthbuhistorybuofbusorebuthroatbuandbupainless,buenlarging,buleft-
sidedbuneckbumass.buTwobucoursesbuofbuantibioticsbuandbuabutrialbuofbucorticosteroidsbudidbu
notbuclearbuthebusorebuthroatbuandbumass.buHebualsobureportsbudysphagiabuwithbusolidsbuan
dbuworseningbuodynophagiabu(painfulbuswallowing),buandbuabu7-
kgbuweightbulossbuoverbuthebulastbu2bumonths.buHisbupastbumedicalbuhistorybuisbusignificantbu
forbuhypertensionbuandbuCOPD,bubothbuwellbucontrolledbuwithbumedication.buHebuhasbuabu5
0-pack-yearbusmokingbuhistory.buPhysicalbuexambufindsbuabu2-
cm,bufirm,bumobile,buandbunontenderbumassbuanteriorbutobuthebusternocleidomastoidbumus
clebuinbuthebupatient'sbumidbuleftbucervicalbulymphbunodebuchain.buTherebuisbunobuoverlyingbu
erythemabuorbuinduration.buThebuoralbucavitybuandbuoropharynxbuarebunormal,buasbuarebuth
ebucranialbunervesbuonbuexam.buBreathbusoundsbuarebuclearbuwithoutbustridorbuorbustertor.bu
Flexiblebufiberopticbularyngoscopybudemonstratesbuabuthickenedbuepiglottisbuwithbuanbuulc
eratingbuandbunecroticbumassbuonbuitsbularyngealbusurfacebuthatbuextendsbutobuinvolvebubot
hbuaryepiglotticbufoldsbuandbuthebuleftbutruebuandbufalsebuvocalbucords.buThebutruebuvocalbuco
rdsbuarebumobilebubilaterallybuandbuappearbunormal.
Non-SmallbuCellbuLungbuCancerbu-buanswer--CommonbuVignette
Abu65-year-oldbumanbupresentsbuwithbuabu2-
monthbuhistorybuofbuabudrybupersistentbucoughbuandbu4.5bukgbuunintentionalbuweightbuloss.bu
Hebudeniesbufevers,budyspnea,busorebuthroat,burhinorrhea,buchestbupain,buorbuhemoptysis.b
uMedicalbuhistorybuisbusignificantbuforbuCOPDbuandbuhypertension.buFamilybuhistorybuisbuno
ncontributory.buHebusmokedbu1bupackbuofbucigarettesbudailybuforbu40buyearsbubutbuquitbu5buy
earsbuago.buNobuadenopathybuisbupalpablebuonbuexaminationbuandbubreathbusoundsbuarebu
diminishedbugloballybuwithoutbufocalbuwheezesbuorburales.
PulmonarybuEmbolismbu-buanswer--CommonbuVignette
, Abu65-year-
oldbumanbupresentsbutobuthebuemergencybudepartmentbuwithbuacutebuonsetbuofbuSOBbuofbu3
0buminutes'buduration.buInitially,buhebufeltbufaintbubutbudidbunotbulosebuconsciousness.buHebui
sbucomplainingbuofbuleft-
sidedbuchestbupainbuthatbuworsensbuonbudeepbuinspiration.buHebuhasbunobuhistorybuofbucardi
opulmonarybudisease.buAbuweekbuagobuhebuunderwentbuabutotalbuleftbuhipbureplacementbua
nd,bufollowingbudischarge,buwasbuonbubedburestbuforbu3budaysbuduebutobupoorlybucontrolledbu
pain.buHebusubsequentlybunoticedbuswellingbuinbuhisbuleftbucalf,buwhichbuisbutenderbuonbuexa
mination.buHisbucurrentbuvitalbusignsburevealbuabufeverbuofbu100.4°Fbu(38.0°C),buheartburateb
u112bubpm,buBPbu95/65bummHg,buandbuanbuO2busaturationbuonburoombuairbuofbu91%.
PulmonarybuArterybuHypertensionbu-buanswer--CommonbuVignette
Abu36-year-oldbuwomanbupresentsbuwithbuabu6-
monthbuhistorybuofbugraduallybuprogressivebudyspneabuonbuexertionbuandbufatigue.buOnbup
hysicalbuexam,buherbuvitalbusignsbuarebunormalbuandbushebuappearsbunotbutobubebuinbuanybudi
stress.buHerbulungsbuarebuclearbutobuauscultation.buHerbucardiacbuexambushowsbuabupromin
entbujugularbuVbuwave,buanbuaccentuatedbupulmonicbucomponentbutobuthebusecondbuheartbu
soundbu(P2),buandbuabuhigh-
pitchedbuholosystolicbumurmurbubestbuheardbuatbuthebuleftbusternalbuborder.
AcutebuBronchitisbu-buanswer--CommonbuVignette
Abu34-year-oldbuwomanbuwithbunobuknownbuunderlyingbulungbudiseasebuhasbuhadbuabu12-
daybuhistorybuofbucoughbuthatbuhasbubecomebuproductivebuofbusputum.buInitiallybushebuwasb
unotbushortbuofbubreath,bubutbunowbushebubecomesbushortbuofbubreathbuwithbuexertion.buSheb
uinitiallybuhadbunasalbucongestionbuandbuabumildbusorebuthroat,bubutbunowbuherbusymptomsbu
arebuallburelatedbutobuabuproductivebucoughbuwithoutbuparoxysms.buShebudeniesbuanybusickb
ucontacts.buOnbuphysicalbuexaminationbushebuisbunotbuinburespiratorybudistressbuandbuisbuaf
ebrilebuwithbunormalbuvitalbusigns.buNobusignsbuofbuURIbuarebunoted.buScatteredbuwheezesbu
arebupresentbudiffuselybuonbulungbuauscultation.
CommunitybuAcquiredbuPneumoniabu-buanswer--CommonbuVignette
Abu54-year-
oldbusmokerbuwithbumultiplebucomorbiditiesbu(diabetes,buhypertension,bucoronarybuarterybu
disease)bupresentsbuwithbuabu2-
daybuhistorybuofbuabuproductivebucoughbuwithbuyellowbusputum,buchestbutightness,buandbufe
ver.buPhysicalbuexamburevealsbuabutemperaturebuofbu101°Fbu(38.3°C),buBPbuofbu150/95bum
mHg,buheartburatebuofbu85bubpm,buandbuaburespiratoryburatebuofbu20bubreathsbuperbuminute.bu
Hisbuoxygenbusaturationbuisbu95%buatburest;bulungbusoundsbuarebudistantbubutbuclear,buwithbu
cracklesbuatbuthebuleftbubase.buCXRburevealsbuabuleftbulowerbulobebuinfiltrate.
HospitalbuAcquiredbuPneumoniabu-buanswer--CommonbuVignettebu
Abu55-year-
oldbumanbuwithbuabuhistorybuofbuperipheralbuvascularbudisease,buwhobupresentsbuwithbuabuco
mplaintbuofbuabuleftbufootbuulcerbuandbupainbuwhenbuwalkingbushortbudistances,buisbufoundbut
obuhavebuabupoplitealbustenosisbuandbuadmittedbuforburevascularization.buFourbudaysbuafter
buadmission,buonbupostoperativebudaybu3,buhebudevelopsbuSOB,buhypoxia,buandbuabuproduc
tivebucough.buAuscultationbuofbuhisbuchestburevealsbudecreasedbubreathbusoundsbuatbuthebul
owerbuaspectbuofbutheburightbusidebuofbuhisbuchest.buHisbumorningbuleukocytebucountbuisbuslig
htlybuhigherbuthanbuthebudaybubefore,buatbu11,000bucells/mL^3.buAnbuanterior-
posteriorbubedsidebuCXRburevealsburightbulowerbulobebuopacity.
