PULMO SERIESSeptember 2013

INTERNS’ ORAL EXAM

CLINICAL CASE

Clinical Case #1• A 71-year-old male is admitted to the hospital with the chief complaint of shortness of breath (SOB) which has had become progressively worse during the last 4-5 days.

He also has had diarrhea for one week. He has had cough productive yellow, blood-tinged sputum, night sweats and urge urinary incontinence for 3 days. He reports no fever or chills. The patient took Imodium (loperamide) over-the-counter (OTC) which helped the diarrhea.

• Past medical history (PMH)Hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home O2 3 L/min, inoperable renal cancer, prostate cancer (had surgery 8 years ago).

•MedicationsCombivent (ipratropium bromide and albuterol sulfate), Cartia XT (diltiazem), Lupron (leuprolide acetate injection), since the surgery for prostate cancer, home O2 3 L/min.

• Social history (SH)Smoker (100 pck-yrs), no EtOH or drugs. Lives with his family.

What is the most likely diagnosis at this point?

Can Pneumonia be diagnosed by history and

PE?

What would you like to do first?

• Physical examination

A thin man in moderate distress. The weight is only 35 kg (5 ft tall). The patient was gradually losing weight according to his family.

VS: 35.8-112-24-161/93.SpO2 94% on 4L.

• Chest: (B) wheezing, right-sided crackles and dullness to percussion.CVS: Clear S1 S2.Abdomen: cachectic, +BS, NT, ND.Extremities: no edema, clubbing or cyanosis.

What would you do next?

Labs?What would you like to do

first?

•ABG: 7.25-31-62-13-SpO2 91% on 4L of O2.

Interpret

What is the value of Chest Xray?

Specific view?

6 months ago current CXR

Should a CXR repeated routinely?

Will you request for a Chest CT scan?

What is your Final Diagnosis?

What microbiologic studies are necessary?

How will you manage this patient?

How long will you give the antibiotic therapy?

Clinical Case # 2• A 46-year-old female with h/o asthma presented to the ER with shortness of breath. This was her 3rd ER visit in the last ten days. She stated that her typical triggers are pet hair and dust. She was sitting in the park this afternoon and developed shortness of breath. Her boyfriend immediately brought her to the ER for evaluation. Five days ago, she was sent home with Prednisone, and albuterol and stated that had been compliant with the medications. She admitted to cocaine use after discharge, but denied any chest pain. She also denied any fever, chills, hemoptysis, leg pain/swelling, productive cough but reported rhinorrhea for 3 days.

• Past medical history (PMH)

Asthma

Medications

Prednisone 20 mg po qd, fluticasone-salmeterol (Advair) 250-50 mcg BID, albuterol PRN

Social history (SH)

Smoking in the past, current cocaine use

Family medical history (FMH)

Asthma in her mother

• Physical examination

Vital signs 110/67-110-98.2 °F (36.8 °C)-28- 89% on RAGeneral appearance: moderate distress, cachectic, frail, acutely ill, disheveled.ENT: Oropharynx clear, no plaques or exudatesRespiratory: Diminished breath sounds. Extensive wheezing throughout.Cardiovascular: no murmurs, no rubs, no gallopsGastrointestinal: soft, NT, ND, no organomegaly, + BSGenitourinary: No CVATMusculoskeletal: No c/c/e, no calf tenderness, normal ROM, equal palpable peripheral pulses and normal strengthSkin: no rashes noted.

What is the most likely diagnosis?

Signs and symptoms that increase the suspicion of

asthma?

What tests would you suggest?

What is spirometry?

What is PEF?

ABG showed pH of 7.36, PaCO2 50, PaO2 107, HCO3 28

CXR: Lungs were mildly hyperinflated, but clear of infiltrate, effusion or pneumothorax.

Interpret

What is your Final Diagnosis?

How will you classify the patient’s asthma by level

of control?

Four components of asthma care?

How will you manage this patient?

Clinical Case #3• A 43 year old non-smoking man was admitted in June 2013 because of rapidly progressive exertional dyspnoea, fever and hemoptysis for one week.

• Past medical history was remarkable only for arterial hypertension, well controlled with amlodipine. He denied exposure to gases, fumes or toxic chemicals. He had never taken any illicit drug in the past.

• At admission the patients was dyspnoeic with 30 breaths/min. Chest examination revealed fine bilateral rales. Physical examination of the heart revealed a regular tachycardia (110 beats/min) with normal heart sounds and no murmurs. Arterial blood pressure was 135/90 mmHg. Abdominal findings were normal. There were no signs of lower extremity deep venous thrombosis. Wells score was -2, rendering the diagnosis of venous thromboembolism very unlikely.

What are your differential diagnoses?

What tests would you request?

• Routine blood tests showed normocromic normocytic anaemia (Hb 11.1 g/dl) with a normal platelet count (118·103/mm3; reference range 80-400·103/mm3).• Coagulation function was normal (aPTT 34 sec, PT 84%, INR 1.13, fibrinogen 559 mg/dl). Urinalysis was unremarkable. ESR 41 mm/h (reference value <15). • Tuberculin skin test (5 U PPD) was negative • Arterial blood gases breathing room air revealed hypoxemia (66 mmHg) and hypocapnia (31 mmHg).• AFB Smear: positive x 2

What is your final diagnosis?

How will you classify this patient’s Tuberculosis?

How will you manage this case?

How will you monitor your patient’s response?

What is the Philippines’ program to ensure

adequate treatment of PTB?

Clinical Case #4• Mrs.D.G., 62 year old woman, is being seen in the emergency room for complaints of increasing shortness of breath. She states that she had the flu approximately 3 weeks earlier and that her breathing has been more difficult since that time.• Her ankles have been swollen for the first time, and sleeping during this time has required “two pillows to support support her.” She states that occasionally she awakens in the middle of the night very short of breath.

• These episodes of noctural dyspnea are relieved by sitting up for several minutes. She has been producing¼cup of yellow sputum since the onset of the flu. Her exercise tolerance was 1 block but is now 20 feet. • Mrs. D.G.started smoking at age 12 and smoked approximately 2 packs of cigarettes a day until she quit 2 years ago.

Based on the history, what is your initial

impression?Key indicators?

Can you make a clinical diagnosis of COPD?

How?

ABG: pH 7.32 , PaC02 62, Pa02 50,HC03 30, Sa02 85%

Interpret.

Based on GOLD, what is the classification of severity of airflow limitation in COPD?

Based on combined assessment of COPD,

what is the patient’s risk?

How will you manage this case?