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These are actual cases to –Stimulate your reading –Test your knowledge of the material Look for the sound icon (usually in the top right portion of the slide)

18 year old male Malaise and purulent nasal discharge Increasing dyspnea and hemoptysis History otherwise unremarkable Physical exam: vitals signs stable, bibasilar crackles, especially at left base Initial Labwork: –Hgb 100 –BUN 17 –Cr 170 –Urinalysis: 3+ red cells

Q1: Interpret the CXR. Answer (Q1)

Q2: How does the CXR help you distinguish amongst the potential causes of hemoptysis? Answer (Q2)

Q3: Based on the clinical, radiologic, and laboratory information presented so far, what are the diagnostic possibilities and your most likely diagnosis? Answer (Q3)

Patient is admitted to hospital Bronchoscopy - alveolar hemorrhage without an airway lesion cANCA positive (1 / 2560 titer), pANCA and anti-GBM negative urine for cytodiagnostics – RBC casts Q4: What should you do next and why? a)CT chest to look for areas of microcavitation b)Repeat bronchoscopy with transbronchial lung biopsy c)Open lung biopsy d)Renal biopsy e)Start empiric treatment with steroids f)Follow Answer (Q4)

Renal biopsy - pauci-immune crescentic, necrotizing glomerulonephritis