Pearls & Pitfalls. 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain 80 pack-year smoker 1 year ago:

Pearls & PitfallsPearls & Pitfalls

63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain

80 pack-year smoker1 year ago: cardiac cath: 3v CAD, not

amenable to CABG/PCI – medical management (beta blocker, ASA, statin)

Severe pain centrally, to left arm and back

BP 180/110, pulse 90, resp 14, afebrileNo CHF, new AI murmurOtherwise unremarkable exam

EKGEKG

You start ASA, give a dose of metoprololCall Cardiology

What is your next step What is your next step (diagnostic/therapeutic?)(diagnostic/therapeutic?)

Aortic dissectionAortic dissection

h/o HTN, “tearing” pain, radiation to back Can dissect into renal / mesenteric / carotid /

coronary arteries (presents as acute MI, as in this case)

New AI murmur from aortic dilatation PITFALL: no thrombolytics/anticoagulation if dissection

suspected Diagnosis confirmed with ECHO, CT, MRI Call CT surgery

Objective: recognize the clinical presentation of aortic dissection

27 year old man is admitted with chest pain after a rear-end motor vehicle accident 6 days ago

belted, 10 mph History of HIV Occasional thrush, no other opportunistic

infections

How do you manage this patient?

1. Tube thoracostomy

2. Bactrim for presumed PCP

Objective: recognize PCP as a cause of spontaneous pneumothorax in patients with HIV

50 year old man is admitted with chest pain

Becomes confused, clammy Bp 90/58, pulse 106, rr 22 Which ABG below would most likely fit the clinical picture?

a) 7.40/40/100 c) 7.32/52/82

b) 7.52/26/90 d) 7.30/28/88

Objective: identify the blood gas findings in a patient with acute MI / cardiogenic shock

You evaluate a 47 year old woman with chronic kidney disease for hypertension. She has no history of diabetes, no cardiac problems, and other medical problems. She has followed a low sodium diet. She does not smoke or drink alcohol.

She is 5’ 8” tall and weighs 230 lbs. BMI is 35.

Blood pressure is 158/92, pulse 70. The exam is unremarkable. She appears well hydrated.

Creatinine is 3.2, glucose 90, and the remainder of the metabolic panel is normal.

Urinalysis shows 2+ proteinuria.

Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future?

a) implementing a low protein diet

b) starting hydrochlorothiazide

c) starting an ACE inhibitor

d) starting amlodipine

e) weight reduction until BMI is ≤ 30

Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future?

a) implementing a low protein diet

b) starting hydrochlorothiazide

c) starting an ACE inhibitor

d) starting amlodipine

e) weight reduction until BMI is ≤ 30

ACE inhibitors and kidney diseaseACE inhibitors and kidney disease Clearly reduce progression to ESRD in diabetic patients (especially

with proteinuria – micro or macro) Nondiabetic patients have similar benefit:

– MDRD trial– Benazapril trial– REIN trial– REIN 2 trial– AASK trial

Even patients with creatinines up to 5.0 mg/dL had reductions in progression to ESRD

Be sure the patient is well hydrated, evaluate diuretic use. AARBs – similar antiproteinuric effect, but outcome trials lacking

Objective: Rx to limit progression renal disease in a 47 y/o woman w/chronic renal insufficiency

64 year old woman with DM II for 20 years, gout, HTN seen in the office No S3, no displacement of PMI, no increased JVD, no rales History of “blood clot,” very high cholesterol (TC 320) Findings below on BOTH legs:

Most likely cause of the exam finding?

a) CHF

b) Nephrotic syndrome

c) DVT

d) Gout

e) An overly aggressive GT3 exam

Objective: identify cause of edema in patients with diabetic nephropathy

35 year old woman with malaise, abdominal pain, diarrhea, nausea/vomiting

Recently

visited here

What are you likely to find on stool gram stain?

a) normal flora

b) large parasites with few eggs, many RBC

c) gram positive rods which are germ tube positive

d) gram positive cocci in grape-like clusters

e) the lost colony of Atlantis

Objective: understand the most common cause of traveler’s diarrhea and how to identify it

You see a 32 year old man in the emergency department for fever, stiff neck and malaise. He has a petechial rash on his ankle. Gram stain of his CSF shows the following:

What therapy is warranted for the household family members of this patient?

a) no therapy, watchful waiting is appropriate

b) Penicillin V-K, 500 mg orally three times daily x 7 days

c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)

d) meningococcal vaccine, post-exposure dose

e) respiratory isolation, culture anterior nares, no therapy

What therapy is warranted for the household family members of this patient?

a) no therapy, watchful waiting is appropriate

b) Penicillin V-K, 500 mg orally three times daily x 7 days

c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)

d) meningococcal vaccine, post-exposure dose

e) respiratory isolation, culture anterior nares, no therapy

Objective: recognize drug treatment for the family of a patient with meningococcal meningitis.

Meningococcal prophylaixsMeningococcal prophylaixs Indicated for high risk exposure:

– household contacts– >4 hours spent with patient for 5 of 7 days prior– dorms, barrack roommates, day care– mouth-to-mouth

Prophylaxis regimens:– rifampin (600mg q 12h x 4) – there is resistance to

rifampin in some areas– cipro 500-750 mg x 1– ceftriaxone 250 mg IM x 1

35 year old man with this finding on tuberculin skin testing:

He begins treatment. Which of the following will help prevent symptomatic side effects of therapy?a) Vitamin B12, 1000mcg monthlyb) Vitamin B3, 1 mg dailyc) Vitamin B6, 50 mg dailyd) folic acid, 1 mg dailye) Jack Daniels, nightly

Objective: recall the management of side effects of anti-TB

medications

You are consulted to see a 72 year old man whose urine output has diminished 48 hours after aortofemoral bypass grafting. He has Type II diabetes and hypertension, and has had claudication for 1 year, which was angiographically confirmed the morning of surgery.

He appears well hydrated. Blood pressure is 148/84; otherwise vital signs are normal. There is an S4 on exam, but no other abnormalities. Distal pulses are 1+ and symmetric.

Serum creatinine is 2.5 (baseline 1.2).

What is the most likely cause of the renal failure?

a) contrast-induced nephropathy

b) surgical error

c) renal artery thrombosis

d) atheroembolism to the renal artery

e) post-op MI with congestive heart failure

What is the most likely cause of the renal failure?

a) contrast-induced nephropathy

b) surgical error

c) renal artery thrombosis

d) atheroembolism to the renal artery

e) post-op MI with congestive heart failure

Objective: recognize contrast nephropathy.

You are called to admit a 50 year old man from the emergency department for obtundation. The family states he has been complaining of fatigue for nine months, and two weeks of vomiting. He has also lost approximately 20 lbs. over the previous two months.

He has no other past medical history, and takes no medications. Vital signs:

– BP 96/60 P 88 R 20 T 38.4 C– On exam, the patient is obtunded but responds to painful and loud verbal

stimuli. He grimaces when you palpate his abdomen. You notice dark coloration of his palmar creases.

What is the best initial management for this patient?

a) Broad spectrum antibiotics

b) Vasopressors

c) Glucocorticoids

d) L-thyroxine

e) Thiamine


a) Broad spectrum antibiotics

b) Vasopressors

c) Glucocorticoids

d) L-thyroxine

e) Thiamine

Objective: Understand initial treatment for a 50 y/o man w/fatigability/vomiting/wt loss/obtunded/brown palmar

creases.

You see a 65 year old woman with Type II Diabetes who complains of exertional pain in the chest for the past three weeks. The episodes last a few minutes, are not associated with nausea or dyspnea, and resolve either with rest or spontaneously. She has no history of cardiac or pulmonary disease. She now presents with a similar episode of chest pain which has lasted about 35 minutes.

Her exam is normal. EKG is completely normal.


a) Admission, cardiac enzymes, medical therapy for acute coronary syndrome

b) Reassurance, prescribe GI cocktail

c) Begin aspirin, schedule outpatient stress test

d) Send for CT of the chest with PE protocol

e) Immediate cardiac catheterization


a) Admission, cardiac enzymes, medical therapy for acute coronary syndrome

b) Reassurance, prescribe GI cocktail

c) Begin aspirin, schedule outpatient stress test

d) Send for CT of the chest with PE protocol

e) Immediate cardiac catheterization

EKG in Acute Coronary SyndromeEKG in Acute Coronary Syndrome

Initial ECG is often not diagnostic in patients with an ACS In two series,

– not diagnostic in 45 percent– normal in 20 percent of patients subsequently shown to

have an acute MI Patients with history suggestive of ischemia / ACS should

be managed as such despite a normal or non-diagnostic EKG

Objective: Manage a 64 yo woman w/type 2 DM with 3 weeks of exertional chest pressure and a normal ECG.

A 62 year old man with a history of chronic bronchitis is admitted to the hospital with lobar pneumonia. He presented to his physician after one day of cough and shortness of breath. He has no other chronic medical conditions. Baseline arterial blood gas is as follows:

pH 7.34 pCO2 68 pO2 60 Vital signs on admission:

– BP 130/80 P 100 R 24 afebrile Pulse oximetry shows an SAO2 of 84% on room air.

He is begun on cefuroxime and azithromycin, oxygen therapy (40% by face mask), and IV fluids.

Twelve hours later, he appears somnolent. Arterial blood gas shows the following:

pH 7.18 pCO2 88 pO2 160

What is the most likely reason for the blood gas findings in this patient?

a) Worsening pneumonia; non-responsive to chosen antibiotics

b) Antibiotic-induced respiratory depression

c) Exacerbation of chronic COPD

d) Reduction in ventilation caused oxygen therapy

e) Exacerbation of heart failure from excessive IV fluids

What is the most likely reason for the blood gas findings in this patient?

a) Worsening pneumonia; non-responsive to chosen antibiotics

b) Antibiotic-induced respiratory depression

c) Exacerbation of chronic COPD

d) Reduction in ventilation caused oxygen therapy

e) Exacerbation of heart failure from excessive IV fluids

Objective: Understand the cause of blood gas changes in a 62 y/o man w/lobar pneumonia and chronic bronchitis.

A 48 year old man with no past medical history complains of six months of pain in his buttocks, especially when walking. He has had no chest pain or shortness of breath, and no leg pain. He is a smoker (1-2 packs per day) since high school but does not drink alcohol. He takes no medications.

Review of systems is positive only for erectile dysfunction; he asks you for a prescription for the “blue pill.”

Further studies would be most likely to show which of the following?

a) Central disc herniation in the L4-L5 area

b) A hard, nodular prostate exam with an elevated PSA

c) Colonic dilatation on CT scan

d) Reduced arterial blood flow in the distal legs

e) Loss of the sacroiliac joint space on plain X-rays

Further studies would be most likely to show which of the following?

a) Central disc herniation in the L4-L5 area

b) A hard, nodular prostate exam with an elevated PSA

c) Colonic dilatation on CT scan

d) Reduced arterial blood flow in the distal legs

e) Loss of the sacroiliac joint space on plain X-rays

Objective: Diagnosis in a 48 y/o man with a 6-month history of pain in the buttocks w/walking and erectile dysfunction.

An 80 year old woman complains of fatigue and weakness for the past two months. She has otherwise been in good health, and takes no medications. Her age-appropriate cancer screening is up to date.

She appears well but pale. Vital signs are normal. There is loss of vibratory and position sense of both legs.

Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear is shown below:

What is the most likely diagnosis in this patient?

Pernicious anemiaPernicious anemia Vitamin B12 deficiency Megaloblastic anemia (hypersegmented PMN) MCV often very high (>110) Other cell lines may be affected in severe disease “Subacute combined degeneration of the posterior

(and lateral) columns” - neurologic disease not seen with folic acid deficiency– Paresthesias, ataxia, vibratory/position sense

Objective: diagnose a patient with fatigue / anemia, a hemoglobin of 9, and an abnormal peripheral blood smear

You see a patient with knee pain and this joint aspirate. His liver is slightly enlarged and his blood glucose is 211. How do you work up the underlying hereditary disorder?

Transferrin saturation (UIBC): Fe/TIBC [HFE gene]

DX: CPPD/hemachromatosis (hyperparathyroidism, hypomagnesemia, hypophosphatemia)

A 59 year old man with a history of alcoholism is admitted to the hospital for cellulitis. He is coherent, and MMSE is 28/30.

Upon admission, his blood alcohol level is 10 mg/dL (BAC = 0.01). He is begun on antibiotics.

24 hours later, you are called to evaluate him for “altered mental status.” He is afebrile; no rash is noted. His MMSE is 27/30, and his neurologic exam is non-focal. He describes “spiders” crawling on the walls and on his arms, and thinks he saw his dead mother sitting in the nurses station.

WBC is normal.

What is the most likely cause of this patient’s change in mental status?

a) Delirium tremens

b) Vitamin B12 deficiency

c) Acute Wernicke’s encephalopathy

d) Alcoholic hallucinosis

e) Adverse effect of antibiotics

What is the most likely cause of this patient’s change in mental status?

a) Delirium tremens

b) Vitamin B12 deficiency

c) Acute Wernicke’s encephalopathy

d) Alcoholic hallucinosis

e) Adverse effect of antibiotics

Alcohol withdrawal syndromesAlcohol withdrawal syndromes Acute Wernicke’s usually rapid onset after administration

of glucose in patients with underlying thiamine deficiency Hallucinosis:

– usually visual, but may be auditory– No clouding of sensorium

DTs:– Later manifestation

Objective: explain the change in mental status 24 hours after admission in a patient with alcoholism

You see a 28 year old man with hyperlipidemia. His father, grandfather, and uncle all had coronary artery disease at an early age, and multiple family members have Type II diabetes. He does aerobic exercise regularly.

On exam, he appears well. Height 67 inches, weight 180 lbs. (BMI = 28) Vital signs: bp 126/78 p 52 r 14 t 35.9 His exam is normal. Labs: TC 270 LDL 190 HDL 36 TG 220

You start a statin. In addition to checking liver enzymes in a month, and a fasting serum glucose, what other lab tests would you order?

Objective: recognize secondary causes of hyperlipidemia (hypothyroidism - up to 4% of patients with hyperlipidemia).

TSH

60 year old man, in good health, has a positive FOBT Colonoscopy at age 51 was “normal” Sent for colonoscopy – one polyp is found (pedunculated,

hyperplastic by pathology) When is his next colonoscopy due, assuming no abnormal

signs/symptoms and negative FOBT in the interval?a) 6 monthsb) 1 yearc) 3 yearsd) 7-10 yearse) Depends upon polyp size

Hyperplastic polypsHyperplastic polyps

No malignant potential “routine” screening interval Need to differentiate from adenomatous polyp

(ALL have malignant potential)– Tubular– Tubulovillous– Villous (highest potential)

Sessile polyps – harder to fully remove than pedunculated (but this is simply descriptive, no relation to malignant potential)

You are asked to see a 23 year old man, s/p repair of a torn medial collateral ligament, who has become yellow.

He is healthy, with no chronic medical problems, no medications, no exposures or travel outside the U.S. Up to date with immunizations. No alcohol or drugs.

ROS: recalls similar eye discoloration after “the flu” 2 years ago. Exam: normal except for eye changes above, yellowish skin discoloration HBsAg - Anti-HBS + Anti HBc - HAV ab – AST 40 ALT 36 AlkPhos 110 Bili (T) 3.2 Bili (D) 0.4 CBC, Chem 7 normal

What do you do next?

a) Reassurance, no testing

b) CT abdomen

c) RUQ ultrasound

d) Liver biopsy

Objective: recognize common benign causes of hyperbilirubinemia

(Gilbert’s)

A 22 year old woman is seen for a rash. She was on a camping trip in the Shenandoah Valley one month ago. She has no other symptoms.

On exam, vital signs are normal, and the exam is normal except for the rash pictured below:

What treatment should be begun?

a) doxycycline

b) erythromycin

c) dicloxacillin

d) vancomycin plus bactrim

e) no treatment warranted at this time


a) doxycycline

b) erythromycin

c) dicloxacillin



A 22 year old woman comes to you because she is worried about Lyme disease. One week ago, she went on a camping trip to the Shenandoah valley. On the morning of the second day of the trip, she found a tick on her arm, and removed it with tweezers. She stated it was not easy to remove, but she thinks she removed the entire tick.

On exam, vital signs are normal. There is no redness and no signs of retained tick parts at the site of the bite. There is no rash.


a) doxycycline

b) erythromycin

c) dicloxacillin




a) doxycycline

b) erythromycin

c) dicloxacillin



Lyme diseaseLyme disease

Treatment:– Early localized (EM): doxycycline, amoxicillin, cefuroxime– “more serious disease” (neurologic, cardiac, arthritis): ceftriaxone

Evaluation & treatment after a tick bite– Rare disease unless tick attached for >48 hours– Patients who meet all guidelines for antibiotic prophylaxis should

be treated: Attached tick identified as an adult or nymphal I. scapularis tick Tick is estimated to have been attached for 36 hours Prophylaxis is begun within 72 hours of tick removal Patient was in an endemic area No contraindication to treatment (single dose doxycycline)

You see a 40 year old woman with fever, weakness, pallor, confusion Blood smear is below: Chem-7:

PT 11.6, PTT 28

HIV testing is negative All cultures are negative

What is the most likely diagnosis?

a) AIHA (autoimmune hemolytic anemia)

b) West Nile meningitis

c) DIC (disseminated intravascular coagulation)

d) TTP (Thrombotic thrombocytopenic purpura)

e) Chronic renal failure with sepsis

138 100 42 4.6 20 3.7 104

Objective: recall the clinical / lab findings in TTP

37 year old woman is seen for eye and abdominal pain, and nausea. Her eye feels hard to the touch.

Has this finding:

Acute angle closure glaucoma

Objective: recognize clinical presentation of acute angle closure galucoma

24 year old woman with acute flank pain, hematuria. History of weight loss, intermittent bloody diarrhea over past 12

months.

What is the underlying illness?

Has this skin rash: And this

urinalysis:

Objective: identify extraintestinal manifestations of inflammatory bowel disease (Crohn’s) – Calcium oxalate

crystals / nephrolithiasis, pyoderma gangrenosum

78 year old man with BPH admitted with anuria. Foley inserted, 2100 cc urine in bladder. Creatinine 4.6 EKG:

Initial treatment?

23 year old nurse sees you for a painful finger:

Herpetic Whitlow

Pityriasis rosea

Which vitamin should NOT be used alone in this patient?

Folic acid (folate)

To which non-ID specialist should you send this patient immediately:

Ophthalmologist (herpes ophthalmicus– nasociliary branch)

What immune system dysfunction might be found in this 19 year old man with fever, headache, stiff neck, photophobia, and gram negative diplococci on gram stain of lumbar fluid:

Terminal complement deficiency (neisseria meningitidis)

What is the antibiotic of choice for this 42 year old man who was bitten by his cat?

Amoxicillin/clavulanate (Augmentin) – pasteurella maltocida

A 45 year old CDC scientist presents with fever, headache, malaise, vomiting, and this rash:

What is her mortality?

Variola major: 20-30% if unvaccinated (probably much less if vaccinated – widespread smallpox vaccines stopped around 1972)

Variola minor: 1%

Why do you NOT give steroid eye drops to this 21 year old student complaining of a painful, itchy eye:

HSV keratitis (“dendritic pattern”)

Name the immunization which may prevent overwhelming bacterial sepsis in this patient:

Pneumovax (Howell-Jolly bodies)

Pel-Ebstein fevers and this biopsy finding are associated with which malignancy?

Hodgkin’s (Reed-Sternberg cell)

Acanthosis nigricans

Basophilic stippling

18 year old patient developed this rash after treatment for an upper respiratory infection. He is febrile, very fatigued, and has tender lymph nodes in the back and front of the neck. There is a pharyngeal exudate, a few small red spots on the palate, and a slightly palpable spleen

tip. What do you advise him to avoid?

a) Alcoholb) Contact sportsc) Sulfa-based antibioticsd) Contact with children

under age 5e) Sex, drugs, Rock & Roll

Morbilliform rash common with mono after amox/ampicillin, palatal petechiae + exudates virtually diagnostic of EBV.

What treatment might be helpful for this patient with malaise, fatigue, anemia, thrombocytopenia, elevated PT/PTT and a positive d-dimer?

All Trans Retinoic Acid (ATRA) – PML (M3), associated with DIC. Auer rods seen, t15:17 mutation common.

19 year old man with weight loss, diarrhea Recurrent “bronchitis” This exam finding:

What is the diagnostic test of choice?

Sweat chloride – elevation supports diagnosis of cystic fibrosis

Objective: identify the diagnostic test of choice for cystic fibrosis

48 year old man with cough (bloody), alcohol abuse X-ray:

What is the diagnostic test of choice?Sputum for AFB (TB)

Objective: recognize TB as a causes of upper lobe pneumonia

46 year old woman with HTN and this X ray:

Gram stain shows this organism:

During treatment, she becomes confused. What do you do next?

Lumbar puncture (pneumococcal meningitis)

Objective: recall common causes of meningitis in adults

67 year old woman with ESRD has these lesions on exam:

What is the most likely finding on lab testing?a) normal PT/PTT, platelet count 25K

b) prolonged PT and PTT, normal plateletsc) PT normal, PTT elevated, platelets 400Kd) PT/PTT normal, platelets 130K

Objective: identify lab findings in patients with chronic kidney disease

You see a 27 year old woman for an annual visit. Her blood pressure is 176/88. She is otherwise healthy, no significant family history, no drugs, tobacco or alcohol. Her only exam abnormality is shown on the next slide.

You begin working her up for secondary causes of hypertension. What would you be most likely to find?

a) Creatinine 4.1, creatinine clearance of 18 cc/hr

b) Na 152, K 2.8, adrenal mass on CT

c) Diffuse atherosclerosis of right renal artery on duplex ultrasound

d) Vanillomandelic acid levels of 2,200, metanephrines 1,750 in a 24-hour urine collection

e) A “string of beads” appearance in the distal two thirds of the left renal artery on renal angiography

Objective: recognize the most common cause of secondary HTN in young women (fibromuscular dysplasia)

You admit a 55 year old, alcoholic man s/p tonic–clonic seizure. He is hemodynamically stable, and post-ictal. Chest X-ray findings are below:

What antibiotics do you begin?

a) Clindamycin

b) Metronidazole

c) Amoxicillin

d) Cefuroxime + azithromycin

e) No antibiotics, watchful waiting

f) GORILLAcillin, 8 grams hourly until rash spreads to entire hospital floor

Objective: understand the antibiotic management of aspiration pneumonia

An 80 year old woman complains of fatigue and weakness for the past two months. She has a history of frequent skin infections, which have responded slowly to treatment. Currently, she takes no medications. Her age-appropriate cancer screening is up to date.

She appears well but pale. A few petechiae are noted on the posterior pharynx.

Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear is shown below:

What is the most likely diagnosis in this patient?

Myelodysplastic syndromeMyelodysplastic syndrome Malignant hematologic disorder with abnormal /

inefficient cell production Infection common (abnormal WBCs) Anemia, fatigue Petechiae (thrombocytopenia) Classification:

– RA– RARS– RAEB– CMML– RAEB-t

Pseudo-Pelger-Huet anomaly shown

A 19 year old man complains of knee pain for 2-3 months. He recalls a motorcycle accident 3 months ago, where he “layed down his Harley,” and had multiple contusions and abrasions, but did not seek medical care. He has no chronic medical problems, does not use drugs or alcohol, and takes no medications. Review of systems is positive only for occasional “sweating” episodes.

On exam, vital signs are as follows: 110/70 80 14 38.9° C There is pain with active and passive range of motion of the

right knee, but no overlying erythema.

X rays show periosteal elevation near the tibial plateau.


a) Osteonecrosis

b) Avascular necrosis

c) Osteomyelitis

d) Osteosarcoma

e) Stress fracture


a) Osteonecrosis

b) Avascular necrosis

c) Osteomyelitis

d) Osteosarcoma

e) Stress fracture

Causes of periosteal elevation:

1) Osteomyelitis

2) Osteosarcoma

3) Hypertrophic pulmonary osteoarthropathy

4) Familial pachydermoperiostosis

5) Caffey’s disease

6) Scurvy

7) Sarcoid

Objective: diagnose a young man with knee pain three months after trauma

Pearls & Pitfalls. 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain 80 pack-year smoker 1 year ago:

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patients risk

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