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Education is at the heart of patient care.
A teaching hospital of Harvard Medical School
ChallengingCasesinPulmonary(andCriticalCare)
RichardM.Schwartzstein,MDChief, Division of Pulmonary, Critical Care and Sleep Medicine
Beth Israel Deaconess Medical CenterEllen and Melvin Gordon Professor of Medicine
Harvard Medical School
COPYRIG
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A teaching hospital ofHarvard Medical School
Case1A21yearoldcollegestudentcomestoseeyouaboutapositivePPD.OneofherroommateswasdiagnosedwithM.Tuberculosiseightweeksago.AthirdroommatehadanegativePPDwithapositivecontrol.Shewantstoknowwhatthepositiveskintestmeansandwhatsheneedstodoaboutit.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case1- continuedThepatientfeelscompletelywell.
Herphysicalexamisnormal.
TheCXRisnormal.COPYRIG
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A teaching hospital ofHarvard Medical School
Youtellthepatientthat:1. ShewasexposedtoTBandneedstobetreated
prophylacticallywithINH.2. ShewasinfectedwithTBandneedstobetreated
withINHtocuretheinfection.3. ShewasexposedtoTBanddoesnotneedtobe
treated.4. ShewasinfectedwithTBandneedstobetreated
withthreedrugs.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case2A20yearoldcollegestudentpresents6hoursafteringestinganunknownquantityof“extra-strengthTylenol”tablets.Sheiscomplainingofmildnausea.
Onexamsheissomnolentbutcanbearoused.Vitalsignsarenotablefor:BP=110/70, HR=110,RR=14.Theabdomenissoftandwithoutguardingortenderness.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case2- Continued• Thereisaconcernthatshemayhavealsotakenvaliumprescribedforafriend.Thepatientisnotbeingverycooperativere:answeringquestions.Shejustbrokeupwithherboyfriendandkeepsmutteringthatshe“wantstodie.”
• ElectrolytesandLFT’sarenormalCOPYRIG
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A teaching hospital ofHarvard Medical School
Yourapproachatthistimeshouldbe:1.Sendtoxicscreenandawaitacetaminophen levelbeforeproceedingfurther
2.LavagestomachwithEwaldtube3.Administer Ipecac4.Administeractivated charcoal5.AdministerN-acetylcysteine
COPYRIG
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A teaching hospital ofHarvard Medical School
Case3A40yearold“weekendwarrior”injureshiskneeplayingbasketballwithhisson.Hecollidedwithhissondrivingtothebasketandhitthegroundhard.Hehasright-sidedchestwalltendernessandaswollenleftkneethathurtswhenhewalksonit.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case3- Continued• HeisbroughttotheemergencydepartmentofhislocalhospitalwhereaCXRistakenandshowsbilateralhilaradenopathy.ACTscanofthechestandabdomenrevealsnootherabnormalities.
• Onphysicalexam,therearenoenlargedperipheralnodes.Bloodchemistries,LFT’sandCBCareallwithinthenormalrange.
• Untiltoday’sgame,thepatientstateshewasin“perfecthealth.”
COPYRIG
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A teaching hospital ofHarvard Medical School
Youshouldadvise:1.ObservationwithrepeatCXRinthreemonths
2.Bronchoscopy3.Mediastinoscopy4.PPD
COPYRIG
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A teaching hospital ofHarvard Medical School
Case4A28yearoldmancomestotheemergencydepartmentwithacomplaintof1weekofshortnessofbreathandmildpleuriticchestpain.Hehasahistoryofasthma,butdenieschesttightness.Hefiguredhehadpulledamuscle.
Onexam,therearediminishedbreathsoundsontheright,butnowheezes.CXRshowsalargerightpneumothorax.O2satis97%withoutsupplementaloxygen.
Achesttubeisinsertedtore-expandthelung.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case4- ContinuedThirtyminutesafterthelungisre-expanded,thepatientdevelopsacutedyspnea;O2satis85%.
Onphysicalexam,therearediminishedbreathsoundsontheright,althoughbetterthanbeforethechesttubewasinserted.
CXRshowstherightlungisre-expandedbuthasadiffusealveolaropacity.
Thehematocritis39.Thereisnobloodcomingfromthechesttube,andnoapparentairleak.
COPYRIG
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A teaching hospital ofHarvard Medical School
Atthispoint,youshould:
1. Intubatethepatientandstartmechanicalventilation
2. Getthepulmonologisttodoabronchoscopytoassessforpulmonaryhemorrhage
3. Givesupplementaloxygenandobservethepatient
4. CheckcardiacenzymesandadministeradiuretictothepatientCOPYRIG
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A teaching hospital ofHarvard Medical School
Case5A62yearoldmanwithCOPDpresentstotheemergencydepartmentwithincreasingshortnessofbreathfortwodays.Duringthistimehehadincreasedcough,wheezing,andsputumproduction.
Onphysicalexamination,heisusingaccessorymusclesofventilationandhisRR=32.Therearediffusewheezesandrhonchi.ABGonroomair:PO2=45,PCO2=55,pH=7.34.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case5- ContinuedAsyoudiscussingnebulizertreatmentswiththerespiratorytherapist,thenursecomesuptoyouandsaysshewouldliketoputstartthepatientonsupplementaloxygenbymask.
Therespiratorytherapistlookshorrified.
COPYRIG
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A teaching hospital ofHarvard Medical School
Atthispointyoushould:
1.Administersupplementaloxygenalongwithbronchodilators
2.Avoidoxygenbecausethepatientisrelyingupon“hypoxicdrive”tobreathe
3.Immediatelyintubatethepatientandbeginmechanicalventilation
4.PrescribeAtivanfortherespiratorytherapist
COPYRIG
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A teaching hospital ofHarvard Medical School
Case6A30yearoldwomanpresentswiththeacuteonsetofshortnessofbreathfourhoursago.Shehasmildchestdiscomfortondeepbreathing.Shesmokescigarettes,hasahistoryofasthma(usuallyassociatedwithexposuretoallergens),andbrokeheranklesixweeksago.
Onexam,sheisanxiousandinmildrespiratorydistress.RR=26, temp.=100.5° Chestrevealsscatteredwheezes.Thepulseoximetershowsasaturationof94%.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case6- Continued• ABGonroomair:PO2=70,PCO2=28,pH=7.49.
• TheCXRisclear,althoughthelungsappearhyperinflated.
• AV/Qscanwasperformedbecausepatienthasallergytoradiographiccontrast,anditdemonstratesmultiplesubsegmentalperfusiondefectsontherightandisreadas“lowprobability.”
COPYRIG
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A teaching hospital ofHarvard Medical School
WiththeresultsoftheV/Qscaninhand,youshould:
1.Initiatebetaagonistsandsteroids2.Obtainlowerextremityultrasound3.Pre-treatherwithsteroidsandproceedwithacontrast-CT scan
4.Beginanti-coagulation
COPYRIG
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A teaching hospital ofHarvard Medical School
Case7A62yearoldmanisbeingtreatedwithPrednisoneandCytoxanforidiopathicpulmonaryfibrosis.HehasshownimprovementinhisCXR,oxygenation,andpulmonaryfunctionoverthecourseofthreemonths.
Sixweeksagoyoubegantotaperhissteroidsfrom40mgqdto20mgqod.COPYRIG
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A teaching hospital ofHarvard Medical School
Case7- ContinuedInthepastweekhehasbeguntocomplainofanon-productivecoughandincreaseddyspnea.
Hedeniesfeverandchestpain.
Onexam,heappearstobeinmildrespiratorydistress.Temp99,BP140/90,HR100,RR22.Chestauscultationisnotableforbibasilarrales,whichhehashadonpriorvisits.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case7- ContinuedOxygensaturationis85%onroomair(downfrom92%)andaCXRshowsdiffuseinterstitialmarkings,whichareincreasedcomparedto6weeksago.COP
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A teaching hospital ofHarvard Medical School
Atthispoint,youshoulddowhichofthefollowing:
1.Beginonbroadspectrumantibiotics2.Performabronchoscopy3.Performathoracoscopicbiopsy4.Increasethedoseofsteroids.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case8A35yearoldmanpresentswithdyspneaonexertion.Hehasbeeningoodhealthwithnochronicmedicalproblems.Heisactiveandjogs3-4timesaweekfor30minutesatatime.Overthepastseveralmonths,hehasnotedincreasedshortnessofbreathonhisrunsandoccasionallywhencarryingpackagesupstairs.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case8- ContinuedOnphysicalexam,thepatientisthinandwellappearing.Hisvitalsignsarenormal.Theoralexamisnotableforafewwhitepatchesonthebuccalmucosa.Thereareafewenlarged,non-tenderposteriorcervicalandaxillarylymphnodes.Thechestisclearwithgoodairmovementbilaterally.CardiacexamrevealsapronouncedP2.Thereisnoperipheraledema.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case8- ContinuedAnechocardiogram isperformedandshowsanormalaorticandmitralvalveandleftventricularfunction.Thereismoderatetricuspidregurgitationwithanestimatedpulmonaryarterysystolicpressureof60mmHg.Therightventricleismildlydilated.
COPYRIG
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A teaching hospital ofHarvard Medical School
Thepatient’spulmonaryhypertensionismostlikelydueto
1. Elevatedpressuresintheleftheart2. Hypoxemia3. Anacutebloodclotinthelungs4. Changesinthestructureofthepulmonary
arterioles
COPYRIG
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A teaching hospital ofHarvard Medical School
Case9Youareprovidingcareforapatientwithpneumonia,cirrhosisandascites.Inthefirst24hoursofthehospitalization,thepatientrequired6LofcrystalloidtosustainanadequateBP.Inthepastday,urineoutputhasdeclinedandthecreatinineisrising.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case9- ContinuedAdministrationofa500ccbolusofnormalsalinedoesnotincreaseurineoutput.
Onphysicalexam,BP=100/60,HR90.Theabdomenhasbecomeincreasinglyfirm,butisnon-tender.Thereis2+pittingedemaofthelegs.
TheINRis2.5andthealbuminis1.8.
COPYRIG
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A teaching hospital ofHarvard Medical School
Atthispoint,youshould:
1. Administeradiuretic
2. Administeralbumin
3. Performaparacentesis
4. Transfusefreshfrozenplasma(FFP)COPYRIG
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A teaching hospital ofHarvard Medical School
Case10Apatientwithbronchiectasis, worseninglungfunctionandchestradiograph, increasedcough,andweight losscomestoyouforevaluation.
Onphysicalexam,thepatient isthinbutappearscomfortable. BPandHRarenormal;respiratory rateis20.Chestauscultation revealsbilateralrhonchi.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case10- continuedHeundergoessputuminduction.ThesputumculturegrowsMycobacteriumaviumcomplex(MAC)onthreeoccasions.
HetellsyouhehadanegativePPD10yearsago.
COPYRIG
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A teaching hospital ofHarvard Medical School
Atthispointyoushould:
1.PlaceaPPD
2.Assumetheorganismisa“colonizer”andignorethefindings
3.Refertopulmonaryforabronchoscopy
4.BegintherapyforMAC
5.Placethepatientinisolationpendingdeterminationofsensitivityoftheorganismtovariousanti-tuberculosisdrugs.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case11A65yearoldmancomestoseeyouforfollow-upofchronicdyspnea.Hehasa60pack-yearhistoryofsmokingandanFEV1thatis30%ofpredictedandusessupplementalO2athome.Healsosuffersfromchronicsystolicheartfailureandwasrecentlydiuresedforthiswithsomeimprovementinhisshortnessofbreath.Laboratoryresultslastweekshowed:ABG(2LnasalO2):PaO270,PaCO253,pH7.45.SerumK3.7,Bicarbonate33.Youareconcernedabouthisalkalemiaandeffectonhisbreathing.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case11- continued
Atthispointyoushould:
1. PrescribeCPAPorBiPAP
2. Startacetazolamide(Diamox)
3. Replaceserumpotassium
4. Startprogesterone
COPYRIG
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A teaching hospital ofHarvard Medical School
Case12A60yearoldmancomestoseeyouforfollow-upofchronicdyspnea.Hehasa60pack-yearhistoryofsmokingandanFEV1thatis30%ofpredictedandusessupplementalO2athome.Healsosuffersfromchronicsystolicheartfailure.
Laboratoryresultslastweekshowed:ABG(2LnasalO2):PaO270,PaCO234,pH7.41.
COPYRIG
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A teaching hospital ofHarvard Medical School
Youconclude:
1. ThelowPaCO2suggestshisexertionaldyspneaismostlikelyduetoheartfailure.
2. ThelowPaCO2suggestshisexertionaldyspneaismostlikelyduetohisCOPD.
3. ThelowPaCO2suggeststhereisaninteractionbetweentheCOPDandheartfailure.
4. Heneedsahigherdoseofsupplementaloxygen
COPYRIG
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A teaching hospital ofHarvard Medical School
Case13Oneofyourpatientsis56yearsoldand
asksyouaboutgettingaCTscantoscreenforlungcancer.Hehassmokedcigarettes1packperdayX20years.COP
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A teaching hospital ofHarvard Medical School
Youreply:
1. Yes,Iwillscheduleit.
2. No,ithasnotbeenproventosavelives.
3. No,theextraradiationoutweighsanybenefit.
4. No,itistooexpensive.
5. No,youhaven’tsmokedenoughcigarettestoqualify.
6. Yes,Idoanythingmypatientswant(ittakestoolongtoexplainwhytheyshouldn’thavethetest).
COPYRIG
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A teaching hospital ofHarvard Medical School
Case14A22yearoldcollegestudentwithapositivePPDcomestoseeyouabouttreatment.Hehasheardthatheneedstotakeadrugforninemonthstotreatthis,andisdemandingashortercourseoftherapy.
COPYRIG
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A teaching hospital ofHarvard Medical School
Yourecommend:
1. Findanotherdoctor.
2. DoublethedoseofINHandtreatfor4months
3. Giverifampinat600mg/dayfor4months
4. GiverifampinandINHfor4months.COPYRIG
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A teaching hospital ofHarvard Medical School
Question15Youarecalledasamedicalconsultanttoseea58yearoldPortuguesespeakingwomanundergoingaliverbiopsy(forpossibleliverabscess)intheinterventionalradiologydepartment.ShehassuddenlydevelopedacuteshortnessofbreathandtheO2sathasdroppedto92%withhighflowoxygenbymask;shedenieschestpain.Onexam,sheappearsveryanxiouswithuseofaccessorymusclesofbreathing.Shehaswheezesonexamwithgoodbreathsoundsbilaterally.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case15- continuedAtthispoint,youshould:
1. Intubatethepatient
2. Givemorphineandbronchodilators
3. Startantibiotics
4. GetaCTscanofthechest
COPYRIG
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A teaching hospital ofHarvard Medical School
Question16A45yearoldmanisadmittedtoyouwithadiagnosisofpossiblesepsis.Hehasbeenhealthyotherthanforahistoryofhypertension.HerecentlyflewbackfromabusinessmeetinginCalifornia,andhassomeheadcongestion.YoutellhimtogototheEDwhereyouevaluatehim:BPis85/60whichimprovessomewhatwith2Loffluid;BPnow95/70.CXRisclear.WBCis6,000,Hct35.BUN/Creatbeforefluidwas40/1.5.O2satis95%withoutsupplementaloxygen.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case16- continuedThenextbestcourseofactionisto:
1. Givesupplementaloxygen
2. Givemorefluid
3. Placeannasogastrictube
4. Getarenalconsult
5. ObtainachestCTscan
COPYRIG
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A teaching hospital ofHarvard Medical School
Case17Youareseeinga75yearoldwomanwithahistoryofcoloncancerandlongstandinghypertensionwhocomestoyourofficewith2daysofshortnessofbreathandaswollenleftleg.Onexam,shehasapalpablecordandapositiveHoman’ssign;BPis120/85mmHgwithHR110/min.
Yousendherforaquickechocardiogram,whichshowsanestimatedPApressureof70mmHg.ACTAconfirmssegmentalpulmonaryemboli.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case17- continuedOnadmissiontothehospital,youshouldbeconsidering:
1. Thrombolytic therapy
2. Rightheartcatheterization
3. PlacementofanIVCfilter
4. Diuresis
COPYRIG
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A teaching hospital ofHarvard Medical School
Case18A69yearoldmanwithCOPDandchronichypercapnia(baselinePCO2=55mmHg)hasbeenintubatedandventilatedfor10daysbecauseofhypercapnicrespiratoryfailureinthesettingofacutebacterialpneumonia.Hehasbeentreatedwithantibioticsandbronchodilators.
Youarenowassessinghimforpossibleremovalfromtheventilatorandsubsequentextubation.
COPYRIG
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A teaching hospital ofHarvard Medical School
Heisplacedonpressuresupportventilationof5cmH2OwithanFIO2of0.4andobservehim.Thebestpredictorofhisabilitytobesuccessfullyextubatedis:
1.PaO2>60mmHg
2.PaCO2<50mmHg
3.Tidalvolume>5ml/kg
4.Respfrequency/tidalvolumeratio<100
5.Maximalinspiratorypressure>-25mmHg
COPYRIG
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A teaching hospital ofHarvard Medical School
Case19Yesterday,youadmitteda78yearoldmanwithaRLLpneumonia.Helivesinanursinghomeandhasbeennotedtoaspirateperiodically.
Despiteantibiotics,hisoxygenationisworseningandyoutransferhimtotheICUforintubationandinitiationofmechanicalventilation.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case19- ContinuedTheCXRshowsbilateralalveolarinfiltratesandhisPaO2witha100%non-rebreathingmaskinplaceisonly50mmHg.
Thepatientisnowintubatedandtherespiratorytherapistsuggeststhatyouneedtobecarefulaboutcausinglunginjurywiththeventilator.
COPYRIG
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A teaching hospital ofHarvard Medical School
Inconsideringthesettingsfortheventilator,youmustbemostawareof(i.e.,concernedabout):
1.Overdistentionofalveoli(volumetrauma)2.Highpeakairwaypressures(barotrauma)3.Rapidrespiratoryfrequencies4.Highcarbondioxidelevels5.PEEP(positiveend-expiratorypressure)above5cmH2O
COPYRIG
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A teaching hospital ofHarvard Medical School
Case20A37yearoldmanisadmittedtotheICUfromtheEDwithpresumedsepticshock.Bloodculturesarepositiveforstreppneumonia.Heiswarmwithgoodcapillaryrefillintheextremities,butthebloodpressurehasdroppedto70mmHgsystolicandurineoutputis<20cc/hr.
CVP=7cmH2O.HereceivedoneliteroffluidintheEDandispresentlyreceivinghighdosenorepinephrine.
COPYRIG
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A teaching hospital ofHarvard Medical School
Youshouldadvise:1.Beginaphenylephrine(neosynephrine)infusion.
2.Beginadopamineinfusion.3.Beginavasopressininfusion.4.Givemorefluids.
COPYRIG
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A teaching hospital ofHarvard Medical School
Case21A22year-oldcollegestudent isadmitted tothehospitalwithincreasingcough,shortnessofbreath,nausea, andageneralfeelingofbeingunwell.HisO2satis84%withsupplemental oxygenbymask(FIO20.8)andheisabouttobeintubated.CXRshowsbilateralpulmonary infiltrates.WBCis12,000.
COPYRIG
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A teaching hospital ofHarvard Medical School
Atthispoint,youshould:
1. Startantiviralmedicationsforinfluenza
2. Beginonbroadspectrumantibiotics
3. Inquireaboutvaping
4. Getanechocardiogram
COPYRIG
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A teaching hospital ofHarvard Medical School
PathologyofVaping-AssociatedLungInjuryNEJM(17patients- Buttetal.,onLine– October2,2019)Bronchiolitis Mucosal edema,
epithelial sloughing
Foamy macrophage DAD
COPYRIG
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A teaching hospital ofHarvard Medical School
Case22A75yearoldwomanisadmittedtoyoufromtheemergencydepartmentwithhypotension.Shehasafeverto103degrees,BPwas80/40mmHginitially.TheUAshowsmanyWBCsandbacteria.SerumlactatelevelincreasedfromonemeasurementtoanotheronthreeoccasionswhileshewasintheED.Bloodpressureisnow100/60withthepatientreceivingadopamineinfusionat6micrograms/kg/min.
COPYRIG
HT
A teaching hospital ofHarvard Medical School
Basedontherisingserumlactatelevels,youshould:
1. Tellthefamilythatherriskofdyingisincreased
2. Tellthefamilythatshewillneedtobeintubated
3. Tellthefamilythatoncealactateleveliselevated,furtherriseisnotimportant
4. AskthefamilyifshehasbeentakingillicitdrugsCOPYRIG
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