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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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volumes. This also results in increased work of breathing because tidal breathing takes place
on a less compliant part of the pressure/volume curve.
Mismatching of ventilation and pulmonary blood flow is a cause of hypoxia (emphysema is
dead space physiology). Alveolar hypoxia eventually leads to pulmonary hypertension with cor
pulmonale.
Final Diagnosis
Emphysema
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Case 8
Chief Complaint
“I wake up in the middle of the night gasping for air.”
History and Physical Examination
A 50-year-old man is evaluated for a 9-month history of loud snoring and “gasping”
during sleep. He also frequently falls asleep in a chair while reading in the evening. His
medical history is otherwise unremarkable. Patient denies symptoms of narcolepsy
(cataplexy, sleep paralysis and visual hallucinations upon transitioning into sleep) or
restless leg syndrome.
On physical examination his T is afebrile, BP 150/82 mm Hg, pulse 70–80/min, and
respirations 12–14/min; BMI is 36. Neck circumference is 18 inches, with notable
macroglossia, micrognathia and a high arched hard palate.
Differential Diagnosis
Initial Management
Setting: outpatient
Obstructive sleep apnea (OSA)
1.
Primary snoring
2.
Poor sleep hygiene with insufficient sleep syndrome
3.
Hypersomnia of central etiology
4.
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Diagnostic/Therapeutic Plan
Test Results
Discussion
OSA is a common chronic disorder that often requires lifelong care. Cardinal features in adults
include the following:
OSA is an important disorder because patients are at increased risk for poor neurocognitive
performance and adverse medical outcomes, due to repeated arousals and/or hypoxemia during
sleep. The severity and duration of OSA necessary for development of these sequelae vary
among individuals. In addition, moderate to severe untreated OSA has been associated with
increased all-cause and cardiovascular mortality.
The prevalence of OSA in the general adult population is ~20–30% in men and 10–15% in
women if it is defined as an apnea hypopnea index (AHI) >5 events per hour. When defined as
AHI ≥5 events per hour plus at least 1 symptom/sign of OSA, the prevalence is ~15% in men
and 5% in women.
Split night nocturnal polysomography with CPAP titration with apnea hypopnea index >15
Apnea hypopnea index (AHI) of 65 events per hour during the first half of the study
Patient successfully titrated with nasal CPAP mask to pressure 15 cm H20, which alleviated
all respiratory events and resulted in AHI 0.0
Obstructive apneas, hypopneas, or respiratory effort related arousals
Daytime symptoms attributable to disrupted sleep, such as sleepiness, fatigue, or poor
concentration
Signs of disturbed sleep, such as snoring and restlessness
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Well-defined risk factors for OSA include older age, male gender, obesity, craniofacial
abnormalities, and upper airway soft tissue abnormalities. Potential risk factors include
smoking, nasal congestion, and family history. Snoring and daytime sleepiness are common
manifestations of OSA. Additional symptoms and signs include restless sleep, periods of
silence terminated by loud snorts or snoring, nocturnal angina, poor concentration, and
awakening with a sensation of choking, gasping, or smothering. The physical exam can be
normal, although obesity, elevated blood pressure, a narrow airway, and a large neck
circumference are common.
Polysomnography is the preferred diagnostic study when OSA is suspected. There are several
interventions that may benefit patients with OSA. These include behavior modifications
including weight loss, and OSA-specific therapies such as positive airway pressure, oral
appliances, hypoglossal nerve stimulator, and surgery.
The most appropriate next step in treatment is CPAP. Obstructive sleep apnea (OSA) is defined
by upper airway narrowing or collapse resulting in cessation (apnea) or reduction (hypopnea)
in airflow despite ongoing efforts to breathe. Severity is commonly measured using the apnea-
hypopnea index (AHI), the sum of apneas and hypopneas per hour of sleep.
CPAP should be considered first-line therapy in any patient who has OSA and associated
symptoms, particularly excessive daytime sleepiness. Optimal positive airway pressure
therapy may have salutary effects on cardiovascular diseases that are associated with OSA.
Suboptimal adherence to CPAP and bilevel positive airway pressure devices is common in
clinical practice, and rates of discontinuation are high. Therefore, objective monitoring of use
and periodic follow-up are important to ensure adherence.
AHI 5–15 indicates mild OSA
AHI 16–30 indicates moderate sleep apnea
AHI >30 indicates severe OSA
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Final Diagnosis
Obstructive sleep apnea
Nocturnal oxygen therapy alone is inadequate to prevent complications associated with OSA
because it does not correct upper airway obstruction, which is the primary problem related
to oxygen desaturation.
Oral devices may be considered for patients who cannot tolerate or are unwilling to use
positive airway pressure therapy but are usually reserved for patients with mild to moderate
OSA.
Surgery may be indicated for specific underlying surgically correctable craniofacial or
upper airway abnormalities that contribute to OSA, including nasal polyps, nasal septal
deviation, tonsillar enlargement, or retrognathia, although positive airway pressure therapy
may be preferred for such patients.
Upper airway surgery may also be considered in selected patients with OSA who desire
surgery, reject other therapeutic modalities, and can undergo the procedure.
225
Case 9
Chief Complaint
“I’ve been coughing and spitting up yellow stuff.”
History and Physical Examination
A 35-year-old woman is evaluated for a 1-week history of cough associated with yellow
phlegm production. She has a 5-pack-year history of cigarette smoking but stopped
smoking 15 years ago. She received albuterol and ipratropium earlier, but the cough did
not improve. Chest x-ray today shows a right middle lobe nodule. There are no old images
available for comparison. A mammogram and Pap smear earlier this year were normal.
On physical examination she is afebrile, BP is 120/80 mm Hg, pulse 80/min, and
respirations 12-14/min. Heart and lung examination are unremarkable, no wheezing,
rhonchi or rales. S1 and S2 are present with no murmurs, rubs, or gallop. No
lymphadenopathy is noted. Laboratory studies, including CBC and basic metabolic panel,
are normal.
Differential Diagnosis
Malignancy
1.
Bronchogenic carcinoma
Pulmonary metastases
Carcinoid tumors
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Initial Management
Diagnostic/Therapeutic Plan
Test Results
Further Evaluation
Recommendations in “low risk patients” (such as this patient) are to repeat imaging in 3–6
months and confirm there is no growth of the nodule.
Discussion
The nodule described in the results of the CT chest is dense, centrally calcified and smoothly
bordered, consistent with a granuloma. The likelihood that a nodule is malignant depends on
such factors as its size, surface characteristics and the patient’s age, smoking history, and
history of previous malignancy. Nodules with smooth borders are usually benign; nodules with
Benign disease2.
Granulomas
Benign tumors (hamartomas)
Resolving infarction
Rheumatoid and vasculitic nodules
AV malformations
Trauma
Rounded atelectasis
CT chest with IV contrast
Chest CT: dense, centrally calcified smooth contoured 2-cm nodular opacity in right middle
lobe with no mediastinal adenopathy or other lung abnormality
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spiculated borders have a high likelihood of being malignant. Central and diffuse patterns of
calcification are associated with benign disease (the calcifications are described as
“popcorn,” “onion skin,” “bull’s eye.”
Although this patient is at risk for lung cancer secondary to her smoking history, this benign
nodule needs no further evaluation.
Not all patterns of calcification are associated with benign disease. A nodule that has
“eccentric” or “off-center calcification” may be either benign or malignant, and further
evaluation or follow-up is advised. Bronchial carcinoid tumors are low-grade malignant
neoplasms that consist of neuroendocrine cells and account for 1% to 2% of all tumors of the
lung. Patients may present with hemoptysis, have evidence of bronchial obstruction, or be
asymptomatic. Carcinoid tumors are often located within a bronchus, resulting in lobar
atelectasis. A history of malignancy is another indicator of possible cancer. The lung is a
common site of metastasis from various tumors, but this patient does not have a history of
cancer, and metastases are usually multiple, peripheral and not calcified.
Note: Patients age ≥45 with significant tobacco history should receive further work-up. This
may include bronchoscopy with biopsy, open lung biopsy, CT-guided biopsy.
Final Diagnosis
Solitary pulmonary nodule; granuloma
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5
Emergency Medicine
Case 1
Chief Complaint
“Leave me alone!”
History and Physical Examination
A 64-year-old man with a history of chronic alcoholism is brought to the emergency
department by the police, who found him agitated, combative, and shouting at imaginary
monsters. Vital signs are T 39 C (102.2 F), BP 130/85 mm Hg, pulse 110/min, and
respirations 24/min.
The patient appears disheveled and agitated, and is sweating profusely. He is staring
around. Examination of the head, eyes, ears, nose, and throat shows poor dentition, a
supple neck, and intact cranial nerves. Cardiovascular exam shows tachycardia, with no
rubs or gallops. Lungs are clear and the abdomen is benign. There is no clubbing,
cyanosis, or edema of the extremities, although there is a resting tremor of the hands.
Neurologic exam is nonfocal, and there is no evidence of external injury.
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CCS NOTE
A patient with a high fever on the CCS should undergo blood cultures, chest x-ray, and
urinalysis. This is a generic fever evaluation.
Differential Diagnosis
CCS NOTE
The CCS will value an ‘appropriate process’ more than ‘jumping straight to the
diagnosis.’ Hence, CT scan of the head is acceptable for a patient presenting with fever
and change in mental status, even if the results are normal.
Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Delirium tremens
1.
Alcoholic hallucinosis
2.
Acute intoxication
3.
Acute schizophrenia
4.
Bacterial meningitis
5.
Subdural hematoma
6.
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