Phillip M. Boiselle, MD

A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.

A previously healthy 58-year-old man presented to the emergency department with a 4-week history of gradually progressive dyspnea, facial flushing, and night sweats. Three weeks before presentation, he received the diagnosis of acne rosacea from an outside physician and was given topical treatments, with no relief in symptoms. One week before presentation, he began to notice swelling of the face, neck, and right arm and dysphagia (initially with solids, then progressing to liquids).

A 52-year-old woman presented to her primary care physician complaining of a nonproductive cough and dyspnea on exertion. These symptoms had a subacute onset over 4 weeks before her initial visit. She denied fever, sputum production, hemoptysis, chest pain, palpitations, abdominal pain, nausea, vomiting, and diarrhea. She did not have any known sick contacts.

A 53-year-old woman presented to the emergency department complaining of substernal chest pain that awoke her from sleep. The chest pain was associated with left shoulder numbness, radiating to her back, and was partially alleviated with sublingual nitroglycerin. During this episode, the patient had a cough productive of yellow phlegm and one instance of cough productive of 1 tbs of bright red blood.

A 38-year-old man presented to the emergency department after experiencing the sudden onset of right upper extremity numbness, heaviness, and loss of coordination, which resolved after 20 minutes. He had 2 similar episodes 19 years and 11 years earlier. Diagnostic evaluation (including MRI of the brain, carotid Doppler ultrasonography, and echocardiography) at the time of the second episode was unrevealing.

A 69-year-old man with a history of atrial fibrillation, pulmonary embolism, asthma, and obstructive sleep apnea presented to the emergency department for evaluation of dyspnea and light-headedness. He had been treated for paroxysmal atrial fibrillation over the past 5 years; fairly good control had been achieved with metoprolol and amiodarone. However, over the past several months, he had been experiencing intermittent episodes of atrial fibrillation.

A 52-year-old man presented to his primary care physician with shortness of breath for 5 days, right-sided lower thoracic back pain, and dry cough. The patient was a 15-pack-year cigarette smoker who had emigrated from China to the United States in 1989. He had no significant history of occupational exposure or tuberculosis. He had no significant weight loss, and his past medical history was otherwise unremarkable.

A 65-year-old woman presented to her primary care physician with a 3-month history of worsening cough, now productive of copious blood-tinged secretions. She also reported a recent onset of fever and dyspnea. She denied any chest pain, chills, night sweats, and weight loss.

Abstract: A significant advance in CT imaging is the use of 3-dimensional (3D) reconstruction techniques. A 3D reconstruction, for example, permits a volumetric evaluation of the contours of the airways and displays areas of stricture, or narrowing, more effectively than do routine axial images. External 3D rendering, also called CT bronchography, helps reveal complex airway abnormalities and improves the detection of subtle airway stenoses. Although it is primarily an investigational tool, internal 3D rendering (virtual bronchoscopy) has several potential applications, including assessing airway stenoses, guiding transbronchial biopsy procedures, and screening for lung cancer. Multiplanar reformation imaging methods can aid in the assessment of airway stenoses, airway stents, tracheomalacia, and extrinsic airway compression. A review of multiplanar images can also aid in the planning of stent placement or surgery. (J Respir Dis. 2006;27(8):348-352)

A 37-year-old man presents with new-onset fever and abdominal pain of several days' duration. What does the PA film show, and what further action would you take to arrive at a diagnosis?

Abstract: Advances in CT technology afford the ability to create 3-dimensional (3-D) reconstructions of the airways in only a few minutes. The 2 basic types of 3-D reconstruction imaging methods are CT bronchography, which depicts the external surface of the airways and its relationship to adjacent structures, and virtual bronchoscopy, which allows the viewer to navigate the internal lumen of the airways by a means similar to conventional bronchoscopy. Although axial images are routinely used to evaluate the upper airways, multiplanar reformations in the coronal and sagittal planes also help evaluate upper airway pathology. Coronal multiplanar reformation images are useful in defining the anatomy of the larynx; sagittal images provide excellent delineation of the epiglottis, vallecula, and piriform sinuses. Axial images are the reference standard for assessing tracheal wall thickening and, therefore, may be particularly helpful in the differential diagnosis of tracheal stenosis. (J Respir Dis. 2006;27(6):266-273)

Abstract: The introduction of helical CT dramatically improved the quality of CT images of the airways and other thoracic structures. Multi-detector row CT scanners have made further improvements with respect to spatial resolution, speed, and anatomic coverage. Axial CT images provide valuable information about the airway lumen and wall and adjacent mediastinal and lung structures, but they are limited in their ability to assess airway stenoses and complex airway abnormalities. These limitations can be overcome by multiplanar and 3-dimensional reconstruction images. State-of-the-art scanners allow all of the central airways to be imaged in a few seconds. This speed is particularly valuable for patients who cannot tolerate longer breath-holds and patients who may have tracheomalacia or vocal cord paralysis. (J Respir Dis. 2006;27(5):192-196)

A 37-year-old man presented withnew-onset fever and abdominal painof several days’ duration. No respiratorysymptoms were reported.The patient had a history of multiplestab wounds to the abdomenand back, resulting in chronic backpain and a neurogenic bladder.During a previous hospital admission,he was treated for Enterobacterpyelonephritis with intravenousgentamicin for 12 days.

A 45-year-old man presented to the emergency department (ED) with fever and left-sided pleuritic chest pain. He had been in good health until 4 days earlier, when diffuse myalgias, weakness, and frontal headache developed. Two days later, these symptoms were accompanied by onset of fever (temperature, 39.4°C [103°F]) and left-sided pleuritic chest pain. He denied chills, rigors, shortness of breath, hemoptysis, and cough.

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.