Practicing Serious Illness Conversations in a Pulmonary Medicine Teaching Clinic.

BACKGROUND: Physician trainees in pulmonary medicine are not provided with supervised practice opportunities to gain confidence and skill in having serious illness conversations in the ambulatory setting. OBJECTIVE: We incorporated a palliative medicine attending into an ambulatory pulmonology teaching clinic to provide supervised opportunities for serious illness conversations. METHODS: Trainees in a pulmonary medicine teaching clinic requested supervision from a palliative medicine attending based on a set of evidence-based pulmonary-specific triggers that indicate advanced disease. Semi-structured interviews were conducted to determine the trainee's perceptions of the educational intervention. RESULTS: The palliative medicine attending supervised 8 trainees in 58 patient encounters. The most common trigger for palliative medicine supervision was answering "no" to the "surprise question." At baseline, all trainees cited lack of time as the primary barrier to having serious illness conversations. Themes emerging from post-intervention semi-structured interviews included trainees learning that (1) patients are grateful to have conversations about the severity of their illness, (2) patients do not have a good sense of their prognosis, and (3) with improved skills, these conversations can be conducted efficiently. CONCLUSIONS: Pulmonary medicine trainees were provided practice opportunities for having serious illness conversations under the supervision of the palliative medicine attending. These practice opportunities effected trainee perception on important barriers to further practice.

Rapidly Developing Methicillin-Resistant Staphylococcus Aureus Pericarditis and Pericardial Tamponade.

Methicillin-resistant staphylococcus aureus (MRSA) pericarditis is a rare life-threatening infection. A 46-year-old female with hypertension, acquired immunodeficiency syndrome (AIDS) and recurrent neck abscesses, presented with a neck abscess and sepsis. Bloody purulent drainage from the abscess was found and antibiotics were started. Drainage was positive for MRSA. Four days after, course was complicated by acute pericarditis and pericardial tamponade; pericardial fluid was drained and was positive for MRSA. Vancomycin was continued, and aspirin and colchicine were started. Two days later, there was a recurrent pericardial fluid collection with loculation. Surgery was thought to be dangerous in the setting of CD4 count of 12. She was managed conservatively thereafter, with vancomycin, aspirin and colchicine, and was successfully discharged from the hospital.

Crossing Boundaries: A Rare Case of Cardiac Dysfunction.

Cardiac tumors are relatively rare. Secondary cardiac tumors are by far more common than primary cardiac tumors. Cardiac involvement may occur secondary to hematogenous metastases, direct invasion, or tumor growth into the venous system and extension into the right atrium. Patients can present with a spectrum of conditions, including embolization, obstruction of ventricular outflow tracts, direct invasion of myocardium causing impaired myocardial function, invasion of surrounding tissue, interference with valvular function causing valvular regurgitation, or constitutional non-specific signs and symptoms. Imaging modalities are essential for diagnosis. Management is mostly surgical, but can include other medical strategies as well. We present a case of a 65-year-old male with hepatocellular carcinoma with direct invasion to the heart through the venous system.

A case report of malignant obesity hypoventilation syndrome: A weighty problem in our ICUs.

INTRODUCTION: The obesity epidemic is reflected by increasing numbers of morbidly obese patients being admitted to intensive care units (ICUs). These are complicated patients whose care involves many diagnostic and treatment challenges. We are presenting a fatal case of super obesity, hypoventilation, and multi-organ failure known as malignant obesity hypoventilation syndrome (MOHS). CASE PRESENTATION: 35 year old African American gentleman with a body mass index (BMI) of 115 kg/m2 presented to the hospital with respiratory distress. On admission he was noted to have multi-organ dysfunction including respiratory failure, renal failure, cardiac and liver abnormalities. His hospital course was remarkable for recurrent cardiac arrest following extubation, complicated tracheostomy, and progressive organ failure despite medical therapy. After a 30 day hospitalization, patient and family decided on terminal extubation owing to worsening medical condition and lack of therapeutic and disposition options. DISCUSSION: The super obese present a number of challenges when admitted to the ICU. Patients with respiratory distress are frequently misdiagnosed and treated for asthma and COPD when obesity hypoventilation syndrome (OHS) is more consistent with the clinical picture. OHS in the superobese is often accompanied by multi-system organ dysfunction, a condition with high morbidity and mortality, with limited treatment options. Standard imaging techniques and procedures are made difficult or impossible by body habitus and often require expert intervention. Surgical options have been used in the treatment of the super obese and resulted in rapid weight loss, improvement in respiratory function, as well as improved metabolism and decreased inflammation. The role of surgery in MOHS remains to be elucidated. CONCLUSION: Physicians should be aware of MOHS as a common condition with high morbidity and mortality. Optimal management remains to be determined.

Inhalational anthrax.

Anthrax remains a real threat. In a spore form, it is highly infectious and dispersible. The initial symptoms are similar to those of influenza, and the early stage of inhalational anthrax may not be recognized. Early antibiotic treatment is important to achieving a good outcome. Contrary to historical experience. many patients with even advanced anthrax can be saved with aggressive medical care. Prevention of anthrax infections requires vigilant infection control methods as well as a rational prophylactic plan. All health care providers should be familiar with the symptoms and treatment of this disease. It is hoped that future research will clarify tests for early diagnosis, the best methods of prophylaxis, and the most effective treatments. Unfortunately the threat of bioterrorism, and anthrax in particular, is unlikely to go away.

Squamous cell lung cancer presenting as a malar mass.

INTRODUCTION: Lung cancer metastasizing to the face has rarely been reported and is an even more unusual presentation. CASE: This is the case of a 49-year-old man diagnosed with squamous cell carcinoma of the face, scheduled for resection. Preoperative radiographs revealed a left upper lobe mass, found to be squamous cell carcinoma. Diagnosis was changed to Stage IV primary lung cancer. The patient did not undergo resection. DISCUSSION: No previous cases of primary lung cancer presenting as a malar mass have been reported. Facial lesions can be the presenting feature of primary lung cancer. Discovery of the true primary lesion can alter therapy and prognosis.