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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Karen Kan, MD Class of 2014 February 26, 2013. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Karen Kan, MD Class of 2014 February 26, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 49 year old non-smoking, Bangladeshi woman who presents with 3 years of dyspnea on exertion

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Lived on a rural farm in Bangladesh • Responsible for cooking and domestic chores • Dyspnea on exertion began 3 years prior to admission • Daily cough productive of clear sputum

  4. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • Dyspnea progressively worsened • Limiting her exercise tolerance to “a few blocks” • Her family brought her to the US and she subsequently presented to Bellevue Hospital

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical & Surgical History: None • Social History: • No tobacco, alcohol or drug use • Originally from Bangladesh • Lived on a farm with no nearby factories • Worked indoors cooking for her family • No family history of pulmonary disease • Home Medications: None • No Known Drug Allergies

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was a well-appearing woman, in no acute distress • Vital Signs: 98°F, BP 110/70, HR 60, RR 14 and oxygen saturation 97% on room air • Her pulmonary exam was notable for mild bibasilar inspiratory crackles • The remainder of the exam was normal

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Arterial blood gas on room air: pH 7.48, PaO2 88 mmHg, PaCO2 39 mmHg • ESR 44 mm/hr (17 mm/hr) • The CBC, BMP and hepatic panel were unremarkable

  8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray • Low lung volumes with scattered small nodules throughout all lung zones • Chest CT • Numerous 2-3 mm irregular nodules scattered throughout both lungs, sparing the pleural surface

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • Induced Sputums: Negative for AFB • Pulmonary Function Tests: • FVC 2.06L (80%), FEV1 1.72L (79%), FEV1/FVC 83%, • FRC 2.88L (124%), TLC 3.84L (95%), RV 1.72L (117%) • Diffusing capacity for CO 22.06 mL/min mmHg (130%) • No response to bronchodilators

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • Chronic bronchitis from an environmental exposure

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Patient remained in respiratory isolation until induced sputums were negative for AFB • After imaging and spirometry were performed, she underwent bronchoscopy

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Bronchoscopy showed numerous dark plaques on the bronchus intermedius and the BAL was grossly gray in appearance and had a normal cell differential • Transbronchial biopsy specimens showed anthracosis with thickening of the basement membrane

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Domestically Acquired Particulate Lung Disease (DAPLD) or “hut lung”

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