UME_Pulmonary_Pleural and mediastinal disease - Case. No answer.pptx

hhhhhhh

1. Pleural and Mediastinal Disease Small group learning

2. Required reading before session Before this session, please read the following: Chapters 15 and 16 in Weinberger SE, Cockrill BA, Mandel J. Principles of Pulmonary Medicine. 7 th ed. Elsevier, 2019. These chapters will provide you with an overview of pleural disease and mediastinal disease.

3. Learning objectives Evaluate the findings from analysis of a pleural effusion Correlate common causes of pleural effusions with results of pleural fluid analysis Identify a pneumothorax, and describe risk factors for development of a pneumothorax Evaluate a mediastinal mass found on chest imaging

4. Case 1

5. Case 1 - History A 57 year old man presents with increasing shortness of breath over the last 2 months. His previous medical history is positive for hypertension. He has been a smoker of 2 packs per day for the past 30 years, and he has consumed 4 to 5 alcoholic drinks per day for many years. He denies fever, sweats, or chills. He has noticed a 5 kg weight gain over the past 2 months. His only medication is hydrochlorthiazide for his blood pressure.

6. Case 1 – Questions for discussion (1 st set) What is the important information presented so far in the history? What parts of his physical examination will be of particular interest?

7. Case 1 – Physical examination On physical examination, he appears slightly jaundiced, but he is not in any acute distress. Blood pressure 150/90, oxygen saturation 93%. There is mild scleral icterus. There is no peripheral lymphadenopathy. Chest exam is notable for dullness and absent breath sounds at the right base posteriorly. There are no crackles or wheezes. Cardiac exam reveals an S4 but no S3. There are no cardiac murmurs. Abdomen is obese, and it was not clear if there is either shifting dullness or a fluid wave. Liver could not be palpated, but spleen tip was palpable on deep inspiration. There was no peripheral edema; clubbing was not present.

8. Case 1 – Questions for discussion (2 nd set) What helpful information has been obtained from the physical examination? How do you interpret these physical findings?

9. Case 1 – Chest x-ray What is your interpretation of the chest x-ray? What features of the abnormality support your interpretation? What imaging study could easily confirm your interpretation? Source: radiopaedia.org

10. Case 1 – Questions for discussion (3 rd set) A small catheter is inserted through the chest wall and into the pleural fluid to drain fluid for diagnostic sampling and possibly to alleviate the patient’s dyspnea. 1200 mL of serous fluid was withdrawn. What studies should be sent on the pleural fluid? What simultaneous blood studies should be obtained?

11. Case 1 – Pleural fluid analysis Pleural fluid results: Protein 1.5 g/dL LDH 45 IU/L Glucose 85 mg/dL Cell count: 900 WBC (40% neutrophils) Gram stain: negative Cytology: negative Serum results: Protein 4.2 g/dL LDH 95 IU/L What can you conclude from the results? What criteria did you use in answering the above question?

12. Case 1 – Questions for discussion (4 th set) What are the possible causes of a transudative pleural effusion? What is likely to be the cause in this patient? What is the likely pathophysiologic mechanism for the pleural effusion?

13. Case 2

14. Case 2 – History and physical examination A 45 year old male was well until 5 days ago, when he developed shaking chills, cough with yellow sputum production, and a fever up to 40 o C. He finally sought medical care today because he was developing increasing left pleuritic chest pain over the past 2 days. On examination, he appeared ill and was sweating. Pulse 104 and regular. Temperature 39.8 o C. Oxygen saturation 90%. Chest exam was notable for dullness and decreased breath sounds over the lower half of the left hemithorax. There was also a pleural friction rub near the top of the area that had decreased breath sounds.

15. Case 2 – Questions for discussion (1 st set) What is the definition of “pleuritic chest pain,” and what causes it? What does a pleural friction rub sound like, and what causes it?

16. Case 2 – Chest radiograph Interpret the chest x-ray Is there something strange about the top border of the density? Source: radiopaedia.org

17. Case 2 – Thoracentesis A needle was placed into the fluid under ultrasound guidance and removed 50 mL of cloudy fluid for testing. The following results were obtained on pleural fluid and simultaneous blood studies: Pleural fluid: Protein 4.5 g/dL LDH 340 IU/L Glucose 15 mg/dL Cell count: 7800 WBCs, 97% neutrophils Gram stain: Gram-positive cocci in pairs (diplococci) Serum results: Protein 6.9 g/dL LDH 285 IU/L

18. Case 2 – Questions for discussion (2 nd set) Is the fluid a transudate or an exudate? What are the major causes of an exudate? What other results in the pleural fluid analysis are of interest here?

19. Case 2 – Questions for discussion (set 3) Formulate a diagnosis based on the results of the chest x-ray and the pleural fluid analysis Propose a sequence of events that led to the pleural abnormality

20. Case 2 – Questions for discussion (set 4) What are some of the inflammatory disorders (other than infection) that can cause an exudative pleural effusion? What is the distinction between a parapneumonic effusion and an empyema?

21. Case 2 – Questions for discussion (set 5) What should be done for management of the empyema?

22. Case 3

23. Case 3 – History and physical examination A 21 year old male presents with sudden onset of right-sided chest pain and mild shortness of breath. He has previously been healthy and has no known underlying cardiac or pulmonary disease. On examination, he is tachypneic, with a respiratory rate of 22. Pulse is 84, BP 130/70. He is afebrile. Oxygen saturation is 92% on ambient air. Trachea is midline. Chest examination has decreased breath sounds throughout the right lung. Cardiac examination is unremarkable. There is no clubbing or peripheral edema. A chest x-ray is performed.

24. Case 3 – Chest x-ray The relevant part of the chest x-ray is shown, so that the abnormality is more readily seen. The rest of the x-ray is unremarkable. Interpret the x-ray and identify the abnormality.

25. Case 3 – Questions for discussion (1 st set) What type of pneumothorax is this? What is the likely pathogenesis? What features (not present in this patient) lead to more concern about a pneumothorax?

26. Case 3 – Questions for discussion (2 nd set) What should be done regarding management of this patient’s pneumothorax?

27. Case 3 – Questions for discussion (3 rd set) What are other risk factors for development of a pneumothorax?

28. Case 4

29. Case 4 – History and physical examination A 45 year old woman presents with a 1 month history of a vague discomfort in her upper chest, which is not associated with exertion or any other precipitating factors. On examination, she appears healthy and has normal vital signs. There is no peripheral lymphadenopathy. Her chest and cardiac examinations are normal. There is no clubbing or peripheral edema. A chest x-ray is performed.

30. Case 4 – Chest x-ray, PA and lateral Interpret the x-rays

31. Case 4 – Questions for discussion (1 st set) What are the major causes of an anterior mediastinal mass? What study should be done next?

32. Case 4 – Chest CT scan Identify and interpret the abnormality on the CT scan

33. Case 4 – Questions for discussion (2 nd set) The patient was taken to surgery, where a thymoma was diagnosed and resected. Thymomas are the most common causes of an anterior mediastinal mass, and they can be either benign or malignant. Are there any other medical problems that can be associated with a thymoma?

34. Learning objectives Evaluate the findings from analysis of a pleural effusion Correlate common causes of pleural effusions with results of pleural fluid analysis Identify a pneumothorax, and describe risk factors for development of a pneumothorax Evaluate a mediastinal mass found on chest imaging