Pulmonary Pearls. Medical Pearls. Case 1: Case 1 (cont.): Case 1: What is the Most Likely Diagnosis? Case 1 (cont.):

Transcription

1 Pulmonary Pearls Christopher H. Fanta, MD Pulmonary and Critical Care Division Brigham and Women s Hospital Partners Asthma Center Harvard Medical School Medical Pearls Definition: Medical fact that is not widely known or routinely discussed in medical texts. Useful Not terribly obscure True Case 1: A 67-year-old man presents with progressive exertional dyspnea over 4 weeks. He has a non-productive cough; no chest pain, fever or chills, or hemoptysis. His history is remarkable for cigarette smoking (1 PPD X 40 years). Case 1 (cont.): On review of systems he reports 20 lbs weight loss. He denies orthopnea, paroxysmal nocturnal dyspnea, gastroesophageal reflux, or difficulty swallowing. Case 1 (cont.): He is afebrile, mildly tachypneic (RR=20/min). Examination is remarkable for inspiratory crackles on auscultation of his right hemithorax. Cardiovascular examination is normal. Case 1: What is the Most Likely Diagnosis? 1. Atypical pneumonia 2. Lymphangitic carcinomatosis 3. Aspiration pneumonia 4. Pulmonary edema 5. Pulmonary thromboembolism

2 Case 2: A 52-year-old man complains of fatigue and early morning headaches over the last 4-6 weeks. On his serum chemistry profile, he is noted to have an elevated serum bicarbonate (35 meq/l). He has smoked cigarettes (1-2 PPD) since age 13. He reports chronic a.m. cough and sputum production. He takes no medications and, in particular, no diuretics. His examination is notable for shallow respirations, clear lung fields, and paradoxical inward movement of his abdomen on inspiration when he is lies supine. Recent PFTs (spirometry): FVC = 3.58 L (70% of pred.) FEV 1 = 2.02 L (53% of pred.) FEV 1/FVC = 0.56 Arterial oxygen saturation by pulse oximetry is 93-94%. His chest radiograph is interpreted as normal (poor inspiration). For further evaluation, arterial blood gases are obtained: PO 2 = 65 mm Hg PCO 2 = 60 mm Hg ph = 7.34

3 Case 2: What is the Most Likely Explanation for his Hypercapnia? 1. Asthma 2. COPD 3. Pulmonary embolism 4. Respiratory muscle weakness 5. Kyphoscoliosis Case 3: A 52-year-old woman is referred back to you by her hematologist for further evaluation of her hypoxemia. Case 3 (cont.): She had presented with polycythemia (hematocrit consistently 52-55%). The hematologist measured her arterial oxygen saturation at 86% and suggested (politely) that in her opinion the patient s erythrocytosis was not due to polycythemia vera but more likely was secondary to her hypoxemia. Case 3 (cont.): The patient is a lifelong non-smoker, although both of her parents and now her husband all smoke cigarettes. She has no history of hypertension, diabetes, hyperlipidemia, or known coronary artery disease. Case 3 (cont.): Physical Exam Her examination is notable for obesity (body mass index = 36), jugular venous distention (4 cm above the clavicles), clear chest exam, a prominent second heart sound (P 2 ), and pitting edema to mid-calf bilaterally. Case 3 (cont.): Add l Data Chest X-ray is normal. You confirm her SaO 2 at 86%. With voluntary hyperventilation, her SaO 2 rises to 98%.

4 Case 3: What is the Most Likely Diagnosis? 1. COPD due to second-hand smoke exposure 2. Respiratory muscle weakness due to amyotrophic lateral sclerosis 3. Ischemic cardiomyopathy 4. Recurrent pulmonary thromboemboli 5. Obesity-hypoventilation syndrome Case 4: An 75-year-old woman complains of dyspnea and fatigue. She had been fully active until 6 months ago. She notes gradual progression of her symptoms and can identify no precipitating event at their onset. She denies cough, sputum production, wheezing, chest pains, or hemoptysis. She smokes approx. ¼ pack of cigarettes/day. Her physical examination is normal Her chest X-ray is normal. Spirometry is normal. On more complete pulmonary function testing, lung volumes are normal, but the diffusing capacity for carbon monoxide (DL CO ) is significantly reduced. Oxygen saturation is normal at rest and does not change with exercise. Case 4:What is the Most Likely Explanation for her low DL CO? 1. Anemia 2. Emphysema 3. Multiple, recurrent pulmonary emboli 4. Primary pulmonary hypertension 5. Atrial septal defect with left-to-right shunt

5 Case 5: A 23-year-old woman presents with shortness of breath and wheezing that has not improved with bronchodilators and inhaled corticosteroids. She reports asthma of 2 years duration, progressively worsening over the last 6 months. Her breathing is labored, particularly at night; and her husband reports hearing loud wheezing from her chest when she sleeps. Her medications include high-dose inhaled steroids, a long-acting inhaled beta-agonist bronchodilator, and a leukotriene receptor antagonist. A two-week course of high-dose oral corticosteroids brought only minimal benefit. She has wall-to-wall carpeting at home; no pets; no observed cockroaches or mice. She has seasonal allergic rhinitis, especially in the late summer and early fall. She works as librarian in an old public library building. Physical examination reveals inspiratory and expiratory wheezing. The remainder of her examination is normal. Spirometry results are shown on the next slide. Case 5: What is the Most Likely Explanation for her Refractory Asthma? 1. Gastroesophageal reflux 2. Allergen exposure in the bedroom 3. Occupational asthma with continued work-related exposure 4. Upper airway obstruction mimicking asthma 5. Sinusitis