case file pathoplys

8/10/2019 case file pathoplys

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RESPIRATORY SYSTEM Seminar Va, Vb

Case 1

EB is a 48-year-old man admitted to the hospital for treatment of a "cough" and "shaking chills." The

patient was drinking alcohol heavily before admission and still was intoxicated when seen in the emergencyroom. He relates that for 2 days he has had a cough productive of green sputum. He has not taken his

temperature, but says he has felt warm. On the day of admission, he describes having had a shaking chill, during

which his teeth rattled. He also has felt more short of breath, and his sputum has become blood streaked. Because

he was feeling progressively worse, he called the paramedics and was brought to the emergency room. He has no

history of loss of consciousness or seizures. He has smoked one-and-a-half packs of cigarettes a day for over 30

years. Regarding his alcohol use, the patient relates that he began drinking heavily in his 20s. After his divorce at

age 32, he began drinking even more heavily and started moving around the country. Currently he is not

employed full time but works intermittently doing odd jobs.

Physical examination: His vital signs include an oral temperature of 38.5C, blood pressure of 96/72 mm Hg,

heart rate of 110 beats/min; and respiratory rate of 22 breaths/min. Orthostatic changes are not recorded. HEENT:

head is free of trauma, extraocular movements are full, without nystagmus, tympanic membranes are clear; poor

dentition and periodontal disease are found upon examination of his oropharynx. His neck is without adenopathy,

and the trachea is midline. Chest: normal anteroposterior (AP) diameter. There is dullness to percussion in the

right base. Breath sounds are bronchial over the dullness, with rales. Cardiac: no jugular vein distension (JVD);

point of maximal impulse (PMI) is in normal position and of normal size; S1 is normal; S2 is physiologically

split. There are no murmurs, gallops, or rubs. Abdomen: bowel sounds are present, and his abdomen is

nontender. The liver span is 11 cm to percussion, palpable one finger breath below the right costal margin and

mildly tender. There is no splenomegaly or mass. Stool is occult-blood negative. Extremities: no cyanosis,

clubbing, or edema.

Chest radiographshows a right lower lobe infiltrate.

Laboratory results:CBC: leukocytosis, CRP: increased, PO2: normal, PCO2: decreased, pH: increased, HCO3:normal

Objectives:

1. What is most possible diagnosis in this patient, which of symptoms and PE findings suggest such

diagnosis?

2. What could be the predisposing factor of this disease?

3. What is possible mechanism of hypotension in this patient?

4. What kind of treatment would be recommended to that patient?


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Case 2

PT is a 64-year-old woman who recently was discharged from a local hospital after treatment for a "blood

clot to my lungs." Because her symptoms have not resolved, she comes to clinic seeking a second opinion

concerning the diagnoses rendered during her recent hospitalization. Before her hospitalization, Ms. T had been

in her usual state of health, but during the week before admission, progressive shortness of breath, cough, and

dark yellow sputum had developed. About 2 days before admission, her sputum became "bloody" and she wentto the hospital emergency room for evaluation. At that time, her arterial blood gases were as follows: PaO2 68

mm Hg; PaCO2 48 mm Hg; and pH, 7.41; her hematocrit was 51 %. A chest radiograph showed increased

bronchovesicular markings in the bases. A lung scan showed matched defects, and the findings were interpreted

as indicating a low to moderate probability of pulmonary embolus. She was treated with low-flow oxygen,

broad-spectrum antibiotics, and heparin. After 5 days, she was discharged off antibiotics and put on warfarin

therapy.

Ms. T has been out of the hospital for 14 days and currently complains of increased sputum production and

dyspnea on exertion. Her history is significant for smoking two packs of cigarettes a day for 33 years. She hashad an intermittent cough and sputum production for the past 5 years, especially during the winter months. She

gradually has reduced her level of physical activity because of exertional dyspnea.

Physical examinationreveals a slender woman looking older than her stated years. Vital signs: blood pressure is

110/62 mm Hg; heart rate is 92 beats/min; and respiratory rate is 24 breaths/min. HEENT: supple neck, with a

midline trachea; she has no adenopathy or thyromegaly. Her mouth and throat are clear, without postnasal

discharge. Chest: percussion note is hyper-resonant; bibasilar rhonchi and occasional wheezes are present.

Cardiac: JVP is elevated slightly at 11 cm H2O; S1is normal, S2has a loud pulmonic component, and an S4 is

present, no S3 or murmur is heard. Abdomen: nontender, with no organomegaly or masses. Extremities: 1+

dependent edema of lower extremities; pulses are present and symmetrical, no clubbing; no calf or thigh

tenderness; and no palpable venous cords; leg circumferences are symmetrical.

Spirometryreveals a forced expiratory volume at 1 second (FEV1) of 1,5 L and a vital capacity (VC) of 3,5 L.

Chest radiographshows increased lower lobe markings.

Laboratory tests: PaO2 is 74 mm Hg, PaCO2 is 42 mm Hg, and pH is 7.41.

Objectives:

1. What are most common causes of dyspnea?

2. Count the FEV1/VC ratio. Does this result suggest obstructive or restrictive ventilation impairment?


diagnosis?

4. What could be the cause factor of this disease?



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Case 3

TS is a 50-year-old man who complains of increasing shortness of breath. He had been well until about 8

years ago when "bronchopneumonia", characterized by fever and respiratory distress, developed. At that time he

was hospitalized for approximately a week and recalls that, over the subsequent month, shortness of breath,

wheezing, and cough developed. He saw his physician and was told that he had "asthma." He then quit smoking,

having smoked three packs a day for 30 years. Since then, he has experienced recurrent "asthma attacks," usually

precipitated by respiratory tract infections.

He has no history of eczema or childhood asthma. Most recently, TS has been feeling well, using his

bronchodilator medications, and doing farm work without dyspnea. About 3 days before his appointment, he

developed a "runny nose," mild sore throat, and a nonproductive cough. He then noted increasing shortness of

breath and began using his inhaler four to six times a day. The night before being seen, he was unable to sleep

lying down because of shortness of breath. In addition to respiratory complaints, Mr. S has a 3-year history of an

"acid stomach." Occasionally, he is awakened by heartburn and a sour taste in his mouth.

Physical examination reveals a well-nourished man in moderate respiratory distress and using his accessory

muscles to breathe. Vital signs: his heart rate is 92 beats/min, and his blood pressure is 128/80 mm Hg, with 15

mm of pulsus paradoxes. His respiratory rate is 32 breaths/min, and his oral temperature is 98.4F (36.8C).

Skin: actinic keratoses are noted over his face. HEENT: nasal passages are clear without polyps. His neck shows

no adenopathy or thyromegaly. Chest: clear to percussion, diffuse expiratory wheezes, no rales. Cardiac: no JVD;

his PMI is not palpable, and heart tones are distant. S1and S2are normal, and no additional sounds are present.

Abdomen: non-tender; no organomegaly or masses. Rectal: prostate is 1+ enlarged, stool is occult-blood

negative. Extremities: moderate cyanosis, clubbing, or edema.

Laboratory tests: PaO2 is 65 mm Hg, PaCO2 is 30 mm Hg, and pH is 7.50

Spirometryreveals a forced expiratory volume at 1 second (FEV1) of 1,0 L and a vital capacity (VC) of 3,0 L.

Objectives:

1. Count the FEV1/VC ratio. Does this result suggest obstructive or restrictive ventilation impairment?

2. What could be the triggering factor for that asthma exaggeration?

3. What is the mechanism of disturbances in arterial gas pressure and alkalosis?


Case 4

AM is a 24-year-old woman who has experienced the sudden onset of right-sided pleuritic chest pain 9

days postpartum. She describes the chest pain as being sharp and worse with inspiration. She also complains of


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shortness of breath and a nonproductive cough. She does not report fever or other pulmonary symptoms.

Nine days before she gave birth to a healthy 4,5 kg girl in an uncomplicated vaginal delivery, and they spent less

than 48 hours in the hospital. Ms. M was discharged feeling well and has been home for a week. Her only prior

hospitalization was for the birth of her first child 3 years ago.

Physical examinationreveals a healthy-appearing woman. Her blood pressure is 120/70 mm Hg, her heart rate

is 100 beats/min, and her respiratory rate is 20 breaths/min. Her oral temperature is 37.5C. HEENT: normal

findings. Chest: clear to percussion and auscultation; no rub; no chest wall tenderness. Cardiac: no JVD; normal

S1, physiologically split S2, and no murmurs, gallops, or pericardial rubs. Abdomen: soft without organomegaly

or mass; bimanual examination reveals a nontender postpartum uterus. Extremities: no cyanosis or edema.

Tenderness is present over the proximal right femoral area, and the circumference of the right thigh measures 39

cm and the left, 35 cm. There is no asymmetry at the calf. Homans' sign is negative, and no venous cords are

palpable.

Arterial blood gasesmeasured, while breathing room air, are as follows: pH 7.5; PaCO230 mm Hg; PaO2 90

mm Hg.

Objectives:


diagnosis?

2. What could be the predisposing factor of this disease?

3. What is the mechanism of disturbances in arterial gas pressure and alkalosis?


Case 5

RG is a 31-year-old woman who has been pregnant for 37-weeks. For 24-hours, she has experienced

headache, nausea, vomiting, and fever. She has also noted low back and abdominal pain. She is thought to have a

viral syndrome and is admitted for hydration and observation. Ms. Gs general health is good, and she has no

medical problems. However, four previous pregnancies have ended in spontaneous abortions, and this pregnancyhas been complicated by cervical incompetence, requiring cervical cerclage at 16 weeks. She smoked before

pregnancy, she does not drink alcohol or use drugs.

On admission, her blood pressure is 80/40 mm Hg, her heart rate is 110 beats/min, and her temperature is 38.2C.

When seen initially, her chest is clear to auscultation, and the cardiac examination reveals a normal S 1and S2

with a systolic ejection murmur heard at the base. Her extremity exam reveals edema below the knees, and

reflexes are 2+, without clonus. The fetal heart rate is in the 160/min.

Two days later, her symptoms have abated, but generalized edema and facial puffiness develop. Although her

blood pressure is only 110/80 mm Hg, the edema raises concern about preeclampsia and labor is induced. During

the pitressin infusion, 4+ reflexes develop and intravenous magnesium therapy is instituted. Labor fails to

progress, and she undergoes a cesarean section with epidural anesthesia, with delivery of a healthy infant.


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3. What kind of changes in spirometry would you expect?

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case file pathoplys