Mystery Quiz

Mystery Quiz

July 18, 2009
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 74 year old man complaining of hemoptysis for four days. The patient has a history of hypertension, but had not been followed medically for many years until two weeks earlier when he presented with leg swelling, breathlessness, and atrial flutter. He was admitted, diuresed, begun on antihypertensive medications including hydralazine, aspirin, and anti-coagulated with enoxaparin and warfarin. After discharge, the patient felt well for a few days before…

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Mystery Quiz- The Answer

May 1, 2009
Mystery Quiz- The Answer

Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is sarcoidosis. The CXR shows diffuse, bilateral infiltration with a predominantly nodular pattern. The pulmonary hila are also prominent. The CT image shows innumerable 2-3mm nodules, many of which have a perilymphatic distribution. The lymphatics, in parallel with the pulmonary vasculature, course through the interstitium. Hence, the perilymphatic nodularity has an interstitial distribution and appears as “studding” along the interstitium which is…

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Mystery Quiz

April 28, 2009
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 42 year old man with a history of non-productive cough for several weeks. Three weeks prior to evaluation by the pulmonary service, the patient presented to the ER with a presumed vasovagal syncopal event that occurred on a subway platform. The patient’s prior medical history included allergic sinusitis and nasal polypectomy. Other than cough, the patient denied constitutional symptoms. The patient was not taking any medications.…

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Mystery Quiz- The Answer

March 10, 2009
Mystery Quiz- The Answer

Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is allergic bronchopulmonary aspergillosis (ABPA). The CXR shows right upper lobe opacities, two of which appear round (Image 3, arrow) and another tubular (Image 3, arrowhead), and a left upper lobe opacity which has the characteristics of subsegmental atelectasis (Image 3, double arrows). The CT scan, performed ten days after the CXR, shows central bronchiectasis of the RUL (Image 4, arrows); tubular branching shadows (Image 6, arrow) as…

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Mystery Quiz

March 6, 2009
Mystery Quiz

Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 42 year old male non-smoker with history of poorly controlled asthma (first diagnosed in 1994, recurrent need for steroid treatments but never intubated), severe seasonal allergies with chronic sinusitis, hepatic steatosis, GERD and gout who presented with complaints of five to ten days of myalgias, productive cough, wheezing and chest tightness. His medications included albuterol, fluticasone and formoteral inhalers, montelukast, colchicine, indomethacin prn, and fexofenadine. Exam was significant for T 97.6,…

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Mystery Quiz- The Answer

January 16, 2009
Mystery Quiz- The Answer

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…

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Mystery Quiz

January 8, 2009
Mystery Quiz

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…

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Mystery Quiz- The Answer

November 8, 2008
Mystery Quiz- The Answer

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 lung (Image…

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Mystery Quiz

October 30, 2008
Mystery Quiz

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 90%. PaO2…

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Mystery Quiz- The Answer

September 27, 2008
Mystery Quiz- The Answer

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 sputum culture. The…

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Mystery Quiz

September 19, 2008
Mystery Quiz

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 a white…

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Mystery Quiz- The Answer

July 30, 2008

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…

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