Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today’s case will be the first in an occasional series. It is best read above the fold first, and then going below the fold after digesting the first part adequately. –PalMD
A fifty year-old woman presented to her primary care physician with hemoptysis (bloody cough). She has a history of emphysema and tuberculosis, which was treated about 25 years ago. She has smoked about one pack of cigarettes per day for the last 41 years. She has a productive cough a few months out of every year, but this is the first time that she has had bright red blood in her sputum. She denies any weight loss, and she has stable, mild shortness of breath. She denies chest pain.
[“deny” is medical-speak for having been asked and responded in the negative]
Her physician found her to be relatively hypoxic (low on oxygen) with an oxygen saturation of 89% on room air (normal being in the mid to high nineties). Her lung exam was significant for very quiet breath sounds in all auscultated lung fields. Because of her low oxygen level, he admitted her to the hospital for further work-up.
On evaluation in the hospital, she was indeed hypoxic. A chest X-ray was abnormal, showing a significant amount of scaring with a severe emphysema. Her lab tests were relatively unremarkable, with a hemoglobin of 18.2 g/dL (high) and a sodium of 126 mmol/L (low).
Because of her abnormal chest X-ray, and CT scan was done.
To explain a bit, this picture is a “lung window”, meaning it highlights the parenchymal tissue of the lung. It is also contrast-infused, meaning blood vessels are highlighted. The money shot is the big white ball in upper portion, just right of center.
At this point, it is normal to form a “differential diagnosis”, or a list of possible causes of the patient’s findings.
I’m not looking for sophisticated medical comments (although they are welcome), and I’m happy to expand on any questions.