Syed Amer MBBS
Kenneth Sakata MD
Karen Swanson DO
Department of Pulmonary Medicine
Mayo Clinic Arizona
Scottsdale, AZ
History of Present Illness
A 67-year-old woman presented to the emergency department with a chief complaint of persistent cough of 2 months duration, productive of yellow sputum. Her symptoms progressed to include dyspnea despite an outpatient course of antibiotics, bronchodilators, and corticosteroids. She denied fevers, chills, hemoptysis, or chest pain.
PMH, FH, SH
She was on chronic immunosuppression secondary to a history of liver transplant due to non-alcoholic steatohepatitis and kidney transplant due to calcineurin toxicity. She denied any history of smoking, alcoholism or recreational drug use.
Medications
- Tacrolimus 3.5 mg bid
- Mycophenolate mofetil 720 mg bid
- Fluconazole 100 mg daily
Physical Examination
Vitals: Temperature 37.1°C, respiratory rate 18 breaths/min, heart rate 88 beats/min, blood pressure 130/76 mm Hg, SpO2 95% on room air.
General: Elderly female in no apparent distress.
Lungs: Scattered inspiratory and expiratory squeaks and pops bilaterally, louder in the left lower lobe
The rest of her exam was within normal limits
Laboratory
WBC 4.8 x 103 cells/µL, Hemoglobin 8.0 g/dL, Hematocrit 23.5, Platelets 122 x 103 cells/µL.
Creatinine 1.3, electrolytes, blood urea nitrogen, glucose were within normal limits.
Radiography
Her admission chest x-ray is presented in Figure 1.
Figure 1. Admission chest radiograph.
Which of the following is (are) appropriate at this time? (Click on the correct answer to proceed to the second of 4 panels)
Reference as: Amer S, Sakata K, Swanson K. March 2015 pulmonary case of the month: sticks and stones may break my bronchi. Southwest J Pulm Crit Care. 2015:10(3):99-104. doi: http://dx.doi.org/10.13175/swjpcc026-15 PDF