YOU’RE THE FLIGHT SURGEON
This article was prepared by Lieutenant Ajiri Ikede, M.D., M.P.H., Royal Canadian Navy, Flight Surgeon. You are the flight surgeon seeing patients at a large Air Force base with tertiary care capabilities. Your next patient is a 33-yr-old female helicopter pilot with 300 flight hours. She scheduled this appointment to discuss concerns raised by her squadron commander regarding a noticeable decline in her job performance, particularly in the areas of motivation and attention to detail. Upon questioning, she admits that she just hasn’t felt the same drive as she usually does when it comes to her work, and her mood may be a bit lower than usual. 1. What should you do? A. Put on duties not including flying (DNIF) until you can get to the bottom of the situation. B. Gather a more detailed history and physical. C. Refer to Mental Health for further evaluation. D. Contact her squadron commander for collateral information.
basic training, she was told by a roommate that she snored, but doesn’t know if this still occurs on a regular basis because she lives alone. 3. What now? A. Ear, Nose, & Throat referral. B. Dental referral. C. Calculate an Epworth score and arrange for polysomnography. D. DNIF until further notice.
ANSWER/DISCUSSION 3. C. Her symptoms of fatigue, irritability, decrease in memory function, nonrestorative sleep, sore throat, and morning headache, coupled with slightly elevated blood pressure, polycythemia, and normal thyroid-stimulating hormone, are highly suggestive of sleep apnea (1,8). The Epworth Sleepiness Scale is a validated screening tool for sleep apnea (1). It involves having patients rate their level of sleepiness in various everyday settings. However, the gold-standard test for sleep apnea is polysomnography (PSG) (7). It is very important to inform her that if the PSG reveals she has apnea, it would be disqualifying, but may qualify for a waiver. Ear, Nose, and Throat and Dental referrals may be appropriate if the PSG shows sleep apnea that may be ANSWER/DISCUSSION amenable to treatment with either surgery or a dental appliance (1,2). 1. B. At this point in the patient encounter, the differential diagnosis again, it User would be premature to assign a DNIF status at this point Delivered by IngentaOnce to: Guest is quite large, and more information will be required to appropriately is not having any aeromedically significant symptoms IP:deciding 5.189.201.167 On: Sun,because 26 Junshe 2016 01:52:03 address the patient’s concerns. Although to DNIF without and does Association not have a definitive diagnosis. Copyright: Medical additional information would be an overly safe approach, itAerospace would be premature at this time. A referral to Mental Health without first fully You contact your colleague at the sleep lab and arrange a PSG in assessing her for underlying medical conditions would be incorrect. 2 wk. Results of the sleep study showed an apnea hypopnea index Finally, contacting her squadron commander could undermine the rela(AHI) of 28/h, a respiratory disturbance index (RDI) of 33/h, a supine tionship with your patient, as well as her commander, as you have not AHI of 53/h, minimum Spo2 of 82%, and time with Spo2 < 90% of practiced due diligence in obtaining a complete history. 24 min. The AHI is determined by adding the total number of apnea and hypopnea events and dividing by the number of hours of sleep. On further questioning, a review of systems is unremarkable with RDI assesses the frequency of apnea (complete upper airway obstructhe exception of fatigue, irritability, and intermittent slight headaches tion), hypopnea (partial upper airway obstruction), and arousals from that dissipate without the use of any medication. She also notes that sleep related to respiratory efforts (e.g., snoring). A diagnosis of obher memory doesn’t seem to be quite as sharp as it should be. When structive sleep apnea (OSA) is made if the RDI ⱖ 5 with symptoms asked to provide an example of her memory issues, she reports that or RDI ⱖ 15 without symptoms (1,3). OSA can be classified into mild she has been writing down radio frequencies on her knee-board that (5-15/h), moderate (16-30/h), and severe (greater than 30/h) based on she previously had no difficulty remembering. Medical history is nonthe number of AHIs recorded on PSG (5). There was no evidence of contributory and she is not on any medications. Family history is periodic limb movement disorder or cardiac arrhythmia. Continuous significant for depression in an older sister, hypothyroidism in her positive airway pressure (CPAP) titration found 8 cm H2O was the mother, and type 2 diabetes in her father. Social history reveals that optimal amount of pressure, decreasing the RDI to less than 5/h. Sleep she is single, never married, and lives alone in an apartment. She reefficiency on CPAP was 92%. After being on CPAP for 1 wk, she noted ports drinking three to five alcoholic beverages a week and does not significant improvement in fatigue, headaches, and irritability. She drink to the point of intoxication. Physical examination is unremarkable also reported no longer having to rely on looking up radio frequencies, with the exception of a body mass index of 28 and a blood pressure of although she has continued to write them down just in case. Now that 145/92. she has been diagnosed with OSA, she would like to have a waiver to 2. What is your next step? return to flying duties. A. Order labs including complete blood count, electrolytes, human 4. What should you do now? chorionic gonadotropin, and thyroid-stimulating hormone. A. Recommend a waiver for OSA. B. Schedule follow-up appointment to review lab results. B. Provide education about optimal management of OSA and conC. Get more detailed history about mental health. tinue trial of CPAP. D. All of the above. C. Explain to her that the PSG showed severe OSA, which is disqualifying from flying duties and is unlikely to be waived for ANSWER/DISCUSSION flying status. 2. D. Given her family history of hypothyroidism and depression, coupled with her symptoms of fatigue and irritability, it is reasonable ANSWER/DISCUSSION to complete some routine blood work to check for hypothyroidism, 4. B. It is important to educate her about the chronic nature of OSA, as pregnancy, and anemia. In addition, her elevated blood pressure prowell as strategies to ensure optimal management. This includes using vides yet another indication for further testing (1,4). As with any inthe CPAP every night, ensuring a proper fit, and avoiding alcohol, espevestigation, arranging for timely follow-up is always a good practice. cially close to bedtime. It would be too early to recommend a waiver because she has not yet proven that she is compliant with using CPAP The laboratory investigations are completed and she is seen back in as an effective long-term treatment. Even though she has severe OSA, the clinic 3 d later. All results are within normal limits with the excepshe may still qualify for a waiver if it is adequately treated with CPAP. tion of a slight polycythemia. A closer look at the upper airway anatomy reveals patent nasal passages and average-sized tonsils. Screening At a follow-up sleep clinic visit 1 mo later, she reported using her for clinical depression is negative as only irritability, low mood, and CPAP machine 6 nights a week for 5-6 h. However, her Epworth score poor sleep are positive. She does not report taking naps during the remained elevated at 15. Review of the machine readings revealed daytime, even though she feels tired. Further questioning about her sleep hygiene reveals 6-8 h of nonrestorative sleep each night, with the occasional sore throat and/or headache upon waking. While attending DOI: 10.3357/ASEM.3919.2014 Aviation, Space, and Environmental Medicine x Vol. 85, No. 10 x October 2014
1063
YOU’RE THE FLIGHT SURGEON—IKEDE suboptimal compliance, with an average CPAP use of 3 h 54 min per night. You reiterate the importance of maintaining compliance with the treatment to improve her overall health as well as aid in expediting her return to flying status (6).
REFERENCES 1. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, et al. Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263–76. 2. Iftikhar IH, Hays ER, Iverson MA, Magalang UJ, Maas AK. Effect AEROMEDICAL DISPOSITION of oral appliances on blood pressure in obstructive sleep apnea: This airman has severe OSA, treated with CPAP. Noncompliance a systematic review and meta-analysis. J Clin Sleep Med 2013; with CPAP treatment for just one night leads to impaired performance 9:165–74. the next day. This airman must wear CPAP all night, every night, for a 3. Lurie A. Obstructive sleep apnea in adults: epidemiology, cliniminimum of 5 h/night and for greater than 90% of nights and have cal presentation, and treatment options. Adv Cardiol 2011; a normal maintenance of wakefulness test. She is not yet eligible for 46:1–42. waiver because it is not certain if CPAP is effective or if she will remain 4. Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of compliant with it. Although aviators with mild OSA can be waived for continuous positive airway pressure treatment on blood pressure: full Flying Class II duties, those with moderate or severe OSA require a systematic review and meta-analysis of randomized controlled appropriate treatment before a waiver will be considered. Obstructive trials. J Clin Sleep Med 2012; 8:587–96. sleep apnea is disqualifying for all services, as well as the FAA, due to 5. Padma A, Ramakrishnan N, Narayanan V. Management of obstrucrisk of acute incapacitation resulting from excessive somnolence; tive sleep apnea: a dental perspective. Indian J Dent Res 2007; therefore, this airman will require a Medical Evaluation Board. 18:201–9. IKEDE A. You’re the flight surgeon: obstructive sleep apnea. Aviat 6. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Space Environ Med 2014; 85:1063–4. Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15:343–56. ACKNOWLEDGMENT 7. Sil A, Barr G. Assessment of predictive ability of Epworth scoring The author would like to thank Dr. Lee Ann Baggott, former respirolin screening of patients with sleep apnoea. J Laryngol Otol 2012; ogist for the U.S. Air Force Aeromedical Consult Service, for her help126:372–9. ful suggestions and professional review of this article. The opinions 8. Zhang W, Si LY. Obstructive sleep apnea syndrome (OSAS) and expressed in this paper are those of the author and do not necessarily hypertension: pathogenic mechanisms and possible therapeutic reflect the views of the U.S. Air Force, the Department of Defense, or the Delivered by Ingenta to: Guest User approaches . Ups J Med Sci 2012; 117:370–82. U.S. Government.
IP: 5.189.201.167 On: Sun, 26 Jun 2016 01:52:03 Copyright: Aerospace Medical Association
This article was prepared by Capt. Richard C. Kipp, M.D., M.S., USAF, MC, FS. You’re the flight surgeon at a fighter training base at the end of a long day of clinic. One of your nurses steps into your office to inform you that radiology would like to discuss a critical finding on a left shoulder film that you ordered on an otherwise healthy 45-yr-old male Reserve instructor pilot. As you reach for the phone, you quickly consider what critical findings could exist on a shoulder x-ray serious enough for a call from the radiologist. The radiologist informs you that he visualizes a concerning density along the left heart border and recommends a full chest x-ray to further evaluate the lesion. Although it is the end of the day, he is willing to stay behind to get the film done quickly. He also begins questioning about any possible risk factors that the patient may have for lung opacities. You take the time to open the patient’s medical record and review your encounter. He is a Caucasian nonsmoker. He has no current medical issues, including hypertension or hyperlipidemia. He has a history of moderate alcohol consumption. Fortunately, you are able to contact your pilot on his way home. Making the conversation brief, you ask him to come back to the clinic for another x-ray. While the patient rides back to the clinic, you review the remainder of the exam. On physical exam at the time of the encounter, he was afebrile, with good bilateral breath sounds, normal heart sounds, and unremarkable chest exam. His only complaint was the left shoulder pain for which the x-ray was ordered. Immediately after the repeat film is shot, the pilot is in your office, “What’s up doc? Never been called back like this before. What did you see on the x-ray?” During your discussion of the initial film, your phone rings again and the radiologist informs you that there are three visible lung opacities in the left lung field. He recommends a chest computed tomography (CT) to further evaluate the opacities and asks you to keep him in the loop with the case. After discussing the new results with your patient, he asks you to wait for a few days before informing the squadron commander to let him deal with the information. 1. How do you handle the patient’s request? A. Inform the commander of the situation with his pilot. B. Place the pilot on duties not including flying (DNIF) status. C. Honor the pilot’s wishes and wait to inform the commander. D. Inform the patient that confidentiality prevents you from informing the commander without his wishes. E. A and B. F. B and C.
1064
ANSWER/DISCUSSION 1. F. The patient has a potentially serious medical condition that may impact his ability to fly. The patient’s mental status should also be considered when determining flight status. It is reasonable to ground the pilot as you continue the workup. As you do not have a definitive diagnosis at this time, it is reasonable to wait to inform the pilot’s chain of command, allowing him to discuss the issue with family prior to engaging at work. In regard to option D, physicians in the U.S. military may discuss medical issues affecting the mobility and duty status of service members without the patient’s consent. The pilot accepts grounding status and thanks you for your agreeing to not inform the command at this time. As the weekend is approaching, he tells you that he will inform the commander on Monday; you agree and ask him to let you know when he has done so. The following business day the patient accomplishes the CT scan. You call the off-base radiologist for the results of the scan to expedite the process. Confirming the results of the x-ray, he reports three left-sided pleural-based lesions with a recommendation for a pulmonary consult. 2. The differential diagnosis for pleural-based masses on CT includes which of the following: A. Metastatic disease. B. Mesothelioma. C. Subpleural lipoma. D. Subpleural fibroma. E. Postinfectious granuloma. F. All of the above. ANSWER/DISCUSSION 2. F. Primary tumors of the pleura are relatively rare. Asbestos is associated with the development of malignant mesothelioma and subpleural fibromas, the latter a benign finding. In this case, the patient has no obvious history of exposure to asbestos. Subpleural lipoma is also a benign finding and has a characteristic appearance on CT given that it is a fat-based lesion, making the CT diagnostic. Metastatic disease represents the most common malignant disease of the pleura, with breast and bronchial being the two most common primary sources (4). Given the patient’s lack of smoking history and gender, both are unlikely. Nonpleurally based lesions should also be included in the differential diagnosis. Many military bases are in locations endemic to fungal agents that may affect the respiratory
DOI: 10.3357/ASEM.3911.2014
Aviation, Space, and Environmental Medicine x Vol. 85, No. 10 x October 2014
This article was prepared by Lieutenant Ajiri Ikede, M.D., M.P.H., Royal Canadian Navy, Flight Surgeon. You are the flight surgeon seeing patients at a large Air Force base with tertiary care capabilities. Your next patient is a 33-yr-old female helicopter pilot with 300 flight hours. She scheduled this appointment to discuss concerns raised by her squadron commander regarding a noticeable decline in her job performance, particularly in the areas of motivation and attention to detail. Upon questioning, she admits that she just hasn’t felt the same drive as she usually does when it comes to her work, and her mood may be a bit lower than usual. 1. What should you do? A. Put on duties not including flying (DNIF) until you can get to the bottom of the situation. B. Gather a more detailed history and physical. C. Refer to Mental Health for further evaluation. D. Contact her squadron commander for collateral information.
basic training, she was told by a roommate that she snored, but doesn’t know if this still occurs on a regular basis because she lives alone. 3. What now? A. Ear, Nose, & Throat referral. B. Dental referral. C. Calculate an Epworth score and arrange for polysomnography. D. DNIF until further notice.
ANSWER/DISCUSSION 3. C. Her symptoms of fatigue, irritability, decrease in memory function, nonrestorative sleep, sore throat, and morning headache, coupled with slightly elevated blood pressure, polycythemia, and normal thyroid-stimulating hormone, are highly suggestive of sleep apnea (1,8). The Epworth Sleepiness Scale is a validated screening tool for sleep apnea (1). It involves having patients rate their level of sleepiness in various everyday settings. However, the gold-standard test for sleep apnea is polysomnography (PSG) (7). It is very important to inform her that if the PSG reveals she has apnea, it would be disqualifying, but may qualify for a waiver. Ear, Nose, and Throat and Dental referrals may be appropriate if the PSG shows sleep apnea that may be ANSWER/DISCUSSION amenable to treatment with either surgery or a dental appliance (1,2). 1. B. At this point in the patient encounter, the differential diagnosis again, it User would be premature to assign a DNIF status at this point Delivered by IngentaOnce to: Guest is quite large, and more information will be required to appropriately is not having any aeromedically significant symptoms IP:deciding 5.189.201.167 On: Sun,because 26 Junshe 2016 01:52:03 address the patient’s concerns. Although to DNIF without and does Association not have a definitive diagnosis. Copyright: Medical additional information would be an overly safe approach, itAerospace would be premature at this time. A referral to Mental Health without first fully You contact your colleague at the sleep lab and arrange a PSG in assessing her for underlying medical conditions would be incorrect. 2 wk. Results of the sleep study showed an apnea hypopnea index Finally, contacting her squadron commander could undermine the rela(AHI) of 28/h, a respiratory disturbance index (RDI) of 33/h, a supine tionship with your patient, as well as her commander, as you have not AHI of 53/h, minimum Spo2 of 82%, and time with Spo2 < 90% of practiced due diligence in obtaining a complete history. 24 min. The AHI is determined by adding the total number of apnea and hypopnea events and dividing by the number of hours of sleep. On further questioning, a review of systems is unremarkable with RDI assesses the frequency of apnea (complete upper airway obstructhe exception of fatigue, irritability, and intermittent slight headaches tion), hypopnea (partial upper airway obstruction), and arousals from that dissipate without the use of any medication. She also notes that sleep related to respiratory efforts (e.g., snoring). A diagnosis of obher memory doesn’t seem to be quite as sharp as it should be. When structive sleep apnea (OSA) is made if the RDI ⱖ 5 with symptoms asked to provide an example of her memory issues, she reports that or RDI ⱖ 15 without symptoms (1,3). OSA can be classified into mild she has been writing down radio frequencies on her knee-board that (5-15/h), moderate (16-30/h), and severe (greater than 30/h) based on she previously had no difficulty remembering. Medical history is nonthe number of AHIs recorded on PSG (5). There was no evidence of contributory and she is not on any medications. Family history is periodic limb movement disorder or cardiac arrhythmia. Continuous significant for depression in an older sister, hypothyroidism in her positive airway pressure (CPAP) titration found 8 cm H2O was the mother, and type 2 diabetes in her father. Social history reveals that optimal amount of pressure, decreasing the RDI to less than 5/h. Sleep she is single, never married, and lives alone in an apartment. She reefficiency on CPAP was 92%. After being on CPAP for 1 wk, she noted ports drinking three to five alcoholic beverages a week and does not significant improvement in fatigue, headaches, and irritability. She drink to the point of intoxication. Physical examination is unremarkable also reported no longer having to rely on looking up radio frequencies, with the exception of a body mass index of 28 and a blood pressure of although she has continued to write them down just in case. Now that 145/92. she has been diagnosed with OSA, she would like to have a waiver to 2. What is your next step? return to flying duties. A. Order labs including complete blood count, electrolytes, human 4. What should you do now? chorionic gonadotropin, and thyroid-stimulating hormone. A. Recommend a waiver for OSA. B. Schedule follow-up appointment to review lab results. B. Provide education about optimal management of OSA and conC. Get more detailed history about mental health. tinue trial of CPAP. D. All of the above. C. Explain to her that the PSG showed severe OSA, which is disqualifying from flying duties and is unlikely to be waived for ANSWER/DISCUSSION flying status. 2. D. Given her family history of hypothyroidism and depression, coupled with her symptoms of fatigue and irritability, it is reasonable ANSWER/DISCUSSION to complete some routine blood work to check for hypothyroidism, 4. B. It is important to educate her about the chronic nature of OSA, as pregnancy, and anemia. In addition, her elevated blood pressure prowell as strategies to ensure optimal management. This includes using vides yet another indication for further testing (1,4). As with any inthe CPAP every night, ensuring a proper fit, and avoiding alcohol, espevestigation, arranging for timely follow-up is always a good practice. cially close to bedtime. It would be too early to recommend a waiver because she has not yet proven that she is compliant with using CPAP The laboratory investigations are completed and she is seen back in as an effective long-term treatment. Even though she has severe OSA, the clinic 3 d later. All results are within normal limits with the excepshe may still qualify for a waiver if it is adequately treated with CPAP. tion of a slight polycythemia. A closer look at the upper airway anatomy reveals patent nasal passages and average-sized tonsils. Screening At a follow-up sleep clinic visit 1 mo later, she reported using her for clinical depression is negative as only irritability, low mood, and CPAP machine 6 nights a week for 5-6 h. However, her Epworth score poor sleep are positive. She does not report taking naps during the remained elevated at 15. Review of the machine readings revealed daytime, even though she feels tired. Further questioning about her sleep hygiene reveals 6-8 h of nonrestorative sleep each night, with the occasional sore throat and/or headache upon waking. While attending DOI: 10.3357/ASEM.3919.2014 Aviation, Space, and Environmental Medicine x Vol. 85, No. 10 x October 2014
1063
YOU’RE THE FLIGHT SURGEON—IKEDE suboptimal compliance, with an average CPAP use of 3 h 54 min per night. You reiterate the importance of maintaining compliance with the treatment to improve her overall health as well as aid in expediting her return to flying status (6).
REFERENCES 1. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, et al. Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263–76. 2. Iftikhar IH, Hays ER, Iverson MA, Magalang UJ, Maas AK. Effect AEROMEDICAL DISPOSITION of oral appliances on blood pressure in obstructive sleep apnea: This airman has severe OSA, treated with CPAP. Noncompliance a systematic review and meta-analysis. J Clin Sleep Med 2013; with CPAP treatment for just one night leads to impaired performance 9:165–74. the next day. This airman must wear CPAP all night, every night, for a 3. Lurie A. Obstructive sleep apnea in adults: epidemiology, cliniminimum of 5 h/night and for greater than 90% of nights and have cal presentation, and treatment options. Adv Cardiol 2011; a normal maintenance of wakefulness test. She is not yet eligible for 46:1–42. waiver because it is not certain if CPAP is effective or if she will remain 4. Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of compliant with it. Although aviators with mild OSA can be waived for continuous positive airway pressure treatment on blood pressure: full Flying Class II duties, those with moderate or severe OSA require a systematic review and meta-analysis of randomized controlled appropriate treatment before a waiver will be considered. Obstructive trials. J Clin Sleep Med 2012; 8:587–96. sleep apnea is disqualifying for all services, as well as the FAA, due to 5. Padma A, Ramakrishnan N, Narayanan V. Management of obstrucrisk of acute incapacitation resulting from excessive somnolence; tive sleep apnea: a dental perspective. Indian J Dent Res 2007; therefore, this airman will require a Medical Evaluation Board. 18:201–9. IKEDE A. You’re the flight surgeon: obstructive sleep apnea. Aviat 6. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Space Environ Med 2014; 85:1063–4. Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15:343–56. ACKNOWLEDGMENT 7. Sil A, Barr G. Assessment of predictive ability of Epworth scoring The author would like to thank Dr. Lee Ann Baggott, former respirolin screening of patients with sleep apnoea. J Laryngol Otol 2012; ogist for the U.S. Air Force Aeromedical Consult Service, for her help126:372–9. ful suggestions and professional review of this article. The opinions 8. Zhang W, Si LY. Obstructive sleep apnea syndrome (OSAS) and expressed in this paper are those of the author and do not necessarily hypertension: pathogenic mechanisms and possible therapeutic reflect the views of the U.S. Air Force, the Department of Defense, or the Delivered by Ingenta to: Guest User approaches . Ups J Med Sci 2012; 117:370–82. U.S. Government.
IP: 5.189.201.167 On: Sun, 26 Jun 2016 01:52:03 Copyright: Aerospace Medical Association
This article was prepared by Capt. Richard C. Kipp, M.D., M.S., USAF, MC, FS. You’re the flight surgeon at a fighter training base at the end of a long day of clinic. One of your nurses steps into your office to inform you that radiology would like to discuss a critical finding on a left shoulder film that you ordered on an otherwise healthy 45-yr-old male Reserve instructor pilot. As you reach for the phone, you quickly consider what critical findings could exist on a shoulder x-ray serious enough for a call from the radiologist. The radiologist informs you that he visualizes a concerning density along the left heart border and recommends a full chest x-ray to further evaluate the lesion. Although it is the end of the day, he is willing to stay behind to get the film done quickly. He also begins questioning about any possible risk factors that the patient may have for lung opacities. You take the time to open the patient’s medical record and review your encounter. He is a Caucasian nonsmoker. He has no current medical issues, including hypertension or hyperlipidemia. He has a history of moderate alcohol consumption. Fortunately, you are able to contact your pilot on his way home. Making the conversation brief, you ask him to come back to the clinic for another x-ray. While the patient rides back to the clinic, you review the remainder of the exam. On physical exam at the time of the encounter, he was afebrile, with good bilateral breath sounds, normal heart sounds, and unremarkable chest exam. His only complaint was the left shoulder pain for which the x-ray was ordered. Immediately after the repeat film is shot, the pilot is in your office, “What’s up doc? Never been called back like this before. What did you see on the x-ray?” During your discussion of the initial film, your phone rings again and the radiologist informs you that there are three visible lung opacities in the left lung field. He recommends a chest computed tomography (CT) to further evaluate the opacities and asks you to keep him in the loop with the case. After discussing the new results with your patient, he asks you to wait for a few days before informing the squadron commander to let him deal with the information. 1. How do you handle the patient’s request? A. Inform the commander of the situation with his pilot. B. Place the pilot on duties not including flying (DNIF) status. C. Honor the pilot’s wishes and wait to inform the commander. D. Inform the patient that confidentiality prevents you from informing the commander without his wishes. E. A and B. F. B and C.
1064
ANSWER/DISCUSSION 1. F. The patient has a potentially serious medical condition that may impact his ability to fly. The patient’s mental status should also be considered when determining flight status. It is reasonable to ground the pilot as you continue the workup. As you do not have a definitive diagnosis at this time, it is reasonable to wait to inform the pilot’s chain of command, allowing him to discuss the issue with family prior to engaging at work. In regard to option D, physicians in the U.S. military may discuss medical issues affecting the mobility and duty status of service members without the patient’s consent. The pilot accepts grounding status and thanks you for your agreeing to not inform the command at this time. As the weekend is approaching, he tells you that he will inform the commander on Monday; you agree and ask him to let you know when he has done so. The following business day the patient accomplishes the CT scan. You call the off-base radiologist for the results of the scan to expedite the process. Confirming the results of the x-ray, he reports three left-sided pleural-based lesions with a recommendation for a pulmonary consult. 2. The differential diagnosis for pleural-based masses on CT includes which of the following: A. Metastatic disease. B. Mesothelioma. C. Subpleural lipoma. D. Subpleural fibroma. E. Postinfectious granuloma. F. All of the above. ANSWER/DISCUSSION 2. F. Primary tumors of the pleura are relatively rare. Asbestos is associated with the development of malignant mesothelioma and subpleural fibromas, the latter a benign finding. In this case, the patient has no obvious history of exposure to asbestos. Subpleural lipoma is also a benign finding and has a characteristic appearance on CT given that it is a fat-based lesion, making the CT diagnostic. Metastatic disease represents the most common malignant disease of the pleura, with breast and bronchial being the two most common primary sources (4). Given the patient’s lack of smoking history and gender, both are unlikely. Nonpleurally based lesions should also be included in the differential diagnosis. Many military bases are in locations endemic to fungal agents that may affect the respiratory
DOI: 10.3357/ASEM.3911.2014
Aviation, Space, and Environmental Medicine x Vol. 85, No. 10 x October 2014
