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Slide 1
Marc Freiman Wednesday Pulmonary Conference August 7, 2013 Long
Case
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HPI 50 yo woman from the Dominican republic presenting to
pulmonary clinic for cough 4-5 years Symptoms may have started
after a cold ? Worse in the summer, no temporal relation to
night/day Dry, non-productive DOE 2-3 city blocks, 2 flights of
stairs ROS - Denies HA, sinus congestion, heartburn, reflux. Denies
chest pain, palpitations, orthopnea, PND or edema
Slide 3
PMHx/Soc Hx Vitiligo Denies childhood asthma From DR 3 years
ago Worked in paper shredding factory for 1 yr Currently works in
retail Never smoker No EtOH, illicits
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Physical exam Afeb P 95 130/84 96% RA; BMI 30 (150lbs, 5)
General: comfortable Clear, no wheeze. ? Crackles at bases
bilaterally Neck: supple, no masses, neck nodes not palpable CV:
RRR No m/r/g No cervical LAD, neck supple No desaturation on
exertion
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CXR
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Symptomatic treatment Benadryl Chlorpheniramine
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Return visit Benadryl lets her sleep through the night Still
with continued cough She climbed 3 flights of stairs and became SOB
but did not desaturate - minimal sats 96% HR 120
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PFT
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CT Scan
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CT read LUNGS: There are multiple nodules in both lungs
measuring up to 5 mm. Mosaic attenuation is seen in both lungs most
prominent in the lower lobes suggestive of small airways or small
vessel disease.
VATS biopsy Had bronchoscopy w BAL VATS biopsy for right lung
with RML and RLL biopsy Nodule palpated in RML
Slide 24
Bronchoscopy and VATS results Middle lobe lavage cytology
negative Aerobic, anaerobic, fungal and AFB cultures negative RIGHT
LOWER LOBE BIOPSY: LUNG PARENCHYMA WITH CONGESTION, HEMORRHAGE AND
HEMOSIDERIN LADEN MACROPHAGES. NO TUMOR IDENTIFIED.
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synaptophysin
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chromogranin
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RML biopsy IMMUNOHISTOCHEMICAL STUDIES PERFORMED ON PARAFFIN
EMBEDDED TISSUE (BLOCK A2) SHOWS POSITIVE STAINING FOR
CHROMOGRANIN, SYNAPTOPHYSINMULTIPLE FOCI OF NEUROENDOCRINE TUMOR,
TUMORLETS/ SMALL CARCINOID TUMOR.