Posted by Daniel Frenkel MD PGY-3 and Jeffrey Lorin MD, Assistant Professor, NYU Division of Cardiology
Edited by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The answer to last week’s mystery quiz is accelerated idioventricular rhythm (AIVR)
AIVR is an ectopic ventricular rhythm with intermediate rates between an escape rhythm (<40 bpm) and ventricular tachycardia (>100-120 bpm). It has the usual features of ventricular arrhythmias including AV dissociation, fusion…
Posted by Daniel Frenkel MD PGY-3 and Jeffrey Lorin MD, Assistant Professor, NYU Division of Cardiology
Edited by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 68 year old man with history of smoking, hypertension, hyperlipidemia, and stable exertional angina who presented with an acute posterior wall myocardial infarction. He was found to have a totally occluded left circumflex artery requiring bare metal stent placement. Several hours after stent placement, the nurse calls stating that…
Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The answer to the mystery quiz is heart failure. The CXR shows bibasilar opacities with hilar fullness on the right. The CT images are remarkable for bilateral effusions, with dependent opacities that increase in density along the anterior-posterior axis. The lung appears clear in the anterior zone (Image 5, arrow; Coronal Image 1); ground glass opacification, characterized by parenchymal haziness which does not obscure the underlying pulmonary vessels, is evident in the mid…
Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 61 year old man with a history of diabetes, chronic kidney disease, and poorly controlled hypertension on five medications who was in his usual state of health until three days prior to admission when he noted increasing exertional dyspnea associated with chest pain, abdominal distention, bilateral lower extremity edema (left greater than right).
Exam notable for BP 105/54 (lower than all other prior measurements), HR 74, O2 Saturation…
Posted by Vivian Hayashi MD and Robert Smith MD,
Mystery Quiz Section Editors
The answer to last week’s mystery quiz is pneumatocele/pseudocyst likely due to ventilator associated lung injury (VALI) in a patient with ARDS. The patient had
ARDS on the basis of diffuse infiltrates, hypoxemia with a PaO2/FiO2 <200mmHg, and no strong evidence of LV heart failure. His risk factor for ARDS was pneumonia, evident on his admission CXR with bibasilar infiltrates (R>L); Streptococcus pneumoniae grew on…
Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 76 year old man with history of moderate-to-severe COPD who presented with three days of fever, breathlessness, and productive cough. Past surgical history is significant for vagotomy and partial gastrectomy 16 years earlier and a cholecystectomy 10 months prior to admission. On exam, the patient appeared acutely ill with a blood pressure of 75/45 mmHg, tachycardia, marked hypoxemia and course breath sounds throughout all lung fields. Labs revealed…
Posted by Nishay Chitkara MD, Instructor of Clinical Medicine, Division of Pulmonary and Critical Care Medicine, Vivian Hayashi MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith MD, Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
The answer to last week’s mystery quiz is bacterial pneumonia. A number of possible diagnoses may be considered for the left lower lobe mass-like density refractory to antibiotic therapy. A bronchogenic cyst can occur as a mediastinal or intrapulmonary mass. The…
Posted by Nishay Chitkara MD, Instructor of Clinical Medicine, Division of Pulmonary and Critical Care Medicine, Vivian Hayashi MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith MD, Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
A 49 year old undomiciled male with a history of hepatitis C, mycobacterium avium complex colonization of the lungs, and active alcohol abuse presented with fevers, cough productive of green sputum, and an elevated white blood cell count. His symptoms were persistent despite broad…
Posted by Athena Kritharis MS-3, Vivian Hayashi MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith MD, Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
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The answer to last week’s mystery quiz is giant hemangioma. The CT is highly suggestive of the diagnosis given the peripheral enhancement with hypodense center (Image 1). Had the study been done dynamically, the contrast would have moved centrally. Contrast…
Posted by Athena Kritharis MS-3, Vivian Hayashi MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith MD, Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
The patient is a 42 year old Caucasian woman with no significant past medical history who presents with diffuse abdominal pain for two months that progressed to acute epigastric pain followed by nausea and vomiting. The vomitus was “milky” and contained only food particles. Symptoms were not relieved with over-the-counter antacids. The patient recalls…
Posted By: Vivian Hayashi, MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
The answer to the mystery quiz is lung cancer, in particular, adenocarcinoma with a predominantly bronchoalveolar cell pattern (BAC). The clue to the mystery was the “cough productive of voluminous frothy, watery sputum,” bronchorrhea, which is often the presenting complaint of patients with BAC. Other entries in the differential diagnosis are characterized by cough that is non-productive…
Posted By: Vivian Hayashi, MD, Instructor of Clinical Medicine, Division of General Internal Medicine and Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine
A 78 year old man with a history of ankylosing spondylitis and known cardiac disease associated with congestive heart failure, presented with breathlessness one year prior to admission. Over the most recent months, the patient complained of cough productive of voluminous frothy, watery sputum. Medications included digoxin, furosemide, irbesartan, isosorbide, metoprolol, spirinolactone, simvastatin, and warfarin. The patient…
