Midwest Midwinter Lung Conference: CPC Session
Case 4
Douglas B. Hornick, M.D. and Carl Lawyer, M.D.
Peer Review Status: Not Peer Reviewed
D.W.:
52 y.o. WM veteran presenting with dyspnea, hemoptysis, and
palpitations
The patient was previously healthy except for an Aortic valve
replacement 2 years prior (maintained on warfarin). Approx. 5 weeks
prior to admission he developed flu-like illness. He received
clarithromycin but failed to improved. He developed dyspnea on
exertion approximately 5 days prior to admission, which was
associated with cough productive clear sputum tinged with blood. On
the day of admission he developed palpitations, his dyspnea worsened
(present now at rest), and his cough was now more severe with blood
clots in his sputum. At the Quincy VA clinic his ECG revealed SVT at
a rate of 160, blood pressure adequate and he was transferred to the
Iowa City VAMC. His past medical history was remarkable for
myxomatous degeneration of the Ao valve leading to placement of a 25
mm St. Jude valve. His last echo revealed normal functioning
prothesis, normal LV function and mild mitral regurgitation. Pt was
on cholestyramin besides warfarin. He had a 35 pack-year smoking
history but quit tow years ago. No EtOH use. Physical exam after
spontaneous cardioversion revealed BP 158/52, P98, T37.9, R30. Rales
and rhonchi were heard in the right upper lung field. The heart exam
was notatble for a regular rate and rhythm, mechanical 2nd heart
sound and a systolic ejection murmur. His oxygen saturation on room
air was 89%. Lab revealed a PT 20 n(INR 2.8), Hb 10.9, WBC 6.3. No
other significant lab abnormalities were identified. His Chest x-ray,
V/Q scan and chest CT are shown below.
Click on small images below to magnify
Chest x-ray
V/Q scan. Perfusion study is shown. Ventilation
study was normal.
High resolution Chest CT
What is the most likely diagnosis and what additional test
would you request to confirm your suspicion?