Shout out to R1 Dr. Pokala! You know you’re doing a great job when your attending tries to change your career path!! 🙂
“Dr. Pokala was placed on emergency residency on call for the CF/PH service. I thought he had a good attitude regarding losing a weekend day off, he prepared as if he would continue to follow the patients for several days, asked questions, followed up on lab test, and I felt he gave his best for my patients.
I feel this is a sign of an exemplary resident, and I want him to know it was greatly appreciated.
I know he is interested in heme/onc, but I hope he would consider pulmonary critical care instead one day. ”
Today at #MorningReport we had a case of a common diagnosis with an uncommon presentation.
A patient with recent cancer, s/p kidney transplant on immunosuppression but now with CKDIII came into the hospital for worsening shortness of breath and a dry cough. PA+lateral chest xray showed patchy RLL consolidation with very small bilateral effusions. He was started on antibiotics for community-acquired pneumonia and no JVD, rales and trace bilateral edema.
See the initial PA/lateral CXR:
Over the next 6 hours after lying in his bed, he came significantly more tachynpenic with an ABG of pH 7.42 and pCO2 24 and pO2 56. What do you think?
Repeat portable CXR at that time. Yikes!
Looks like worsening interstitial pattern! Differentials included:
Non-infectious: metastic cancer, pneumotoxicity – COP/BOOP/eos pneumonia 2/2 Tacro or Statin or pneumonitis, PF and DAD 2/2 chemo, DAD, DAH or sarcoid
Hypervolemia from CKD
ACS, heart failure
CT scan confirmed the diagnosis!
Cause of his SOB and acute worsening? Volume!
Patient recieved some diuretics and tachypnea improved dramatically.
Dr. Meredith Greer sent these notes over from our very own, Dr. Abbara, in the Radiology Department: look at the CT chest because there you can see the bilateral pleural effusions looking much bigger as the patient is laying supine and they are sort of layered out. When the pt is getting the PA/L CXR a lot of the effusion can hide in the gutters. It is possible that while the pt was laying down he developed atelectasis on top of his effusions and when he stood upright for the plain film that his effusions went down but the atelectasis didn’t have time to open back up yet.
When approaching patients with Non-Hodgkin’s Lymphoma, screen for chronic infections and treat!!Sometimes treating the underlying HIV, Hep C, Hep B, or other viral etiology can by itself cause the lymphoma to go into remission.