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 emergency
room. 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; S
1
is normal; S
2
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 radiograph shows a right lower lobe infiltrate.
Laboratory results: CBC: leukocytosis, CRP: increased, PO
2
: normal, PCO
2
: decreased, pH: increased, HCO
3
:
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?


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 went
to 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 has
had 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 examination reveals 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 H
2
O; S
1
is normal, S
2
has a loud pulmonic component, and an S
4
is
present, no S
3
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.

Spirometry reveals a forced expiratory volume at 1 second (FEV1) of 1,5 L and a vital capacity (VC) of 3,5 L.
Chest radiograph shows 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 FEV
1
/VC ratio. Does this result suggest obstructive or restrictive ventilation impairment?
3. What is most possible diagnosis in this patient, which of symptoms and PE findings suggest such
diagnosis?
4. What could be the cause factor of this disease?
5. What kind of treatment would be recommended to that patient?


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. S
1
and S
2
are 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
Spirometry reveals 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 FEV
1
/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?
4. What kind of treatment would be recommended to that patient?


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
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 examination reveals 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
S
1
, physiologically split S
2
, 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 gases measured, while breathing room air, are as follows: pH 7.5; PaCO
2
30 mm Hg; PaO
2
90
mm Hg.

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 the mechanism of disturbances in arterial gas pressure and alkalosis?
4. What kind of treatment would be recommended to that patient?


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 pregnancy
has 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
1
and S
2
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.
Forty-eight hours postoperatively, she complains of shortness of breath and a dry cough. At that time, her cardiac
examination reveals a tachycardia but additional sounds are obscured by respiratory noises. Her neck veins
cannot be seen. Pulmonary examination reveals the presence of diffuse rhonchi and wheezing. Generalized
edema is present.

Her blood gases measured when breathing room air are as follows: PaO2, 63 mm Hg; PaCO2, 35 mm Hg; and
pH, 7.43.
A portable chest radiograph shows diffuse pulmonary infiltrates. Her cardiac diameter appears appropriate for
an AP view.
!" What are most common causes of pulmonary edema?
$" What is the probable mechanism of pulmonary edema in this patient?
%" What kind of treatment should be introduced?


Case 6

DC is a 55-year-old man who is admitted with the chief complaint of several months of "increasing
fatigue" and bilateral "leg swelling." He first noted increasing dyspnea 7 years ago but did not seek medical care.
Approximately 3 years ago he was admitted to another hospital for evaluation of a hematocrit of 62%. At that
time, he was noted to have an FEV1 of 1.60 liters, an FVC of 1.95 liters, and the following arterial blood gas
values measured while breathing room air: pH, 7.42, PaCO2. 56 mm Hg, PaO2, 40 mm Hg. He was thought to
have COPD, with secondary hypoxemia, hypercapnia, cor pulmonale, and erythrocytosis. He was treated with
inhaled beta-agonists, diuretics, and supplemental oxygen.
He initially noted some improvement but continued to experience chronic daytime somnolence. Mr. C also
reports experiencing agitated sleep, snoring, morning headaches, and progressive weight gain. He has been obese
"all his life" but has gained 20 pounds (9 kg) in the past 3 weeks. He has a 120 pack year history of smoking and
still smokes two packs daily. He drinks one "stiff drink" each evening. The remainder of his history is
noncontributory.

Physical examination reveals a cyanotic morbidly obese man. Vital signs: blood pressure of 104/74 mm Hg,
heart rate of 100 beats/min, respirations are shallow and the rate is 30 breaths/min, his oral temperature is
37.0C. His height is 70 inches (1.75 m) and his weight is 306 pounds (138 kg). Cardiac: JVP is estimated to be
12 cm H
2
O; normal S
1
, S
2
demonstrates an increased P
2
component, and an S
4
is present. Chest: decreased
breath sounds and bibasilar crackles. Extremities: symmetrical lower extremity edema to the thighs. Neurologic
examination reveals that the patient is somnolent and dozes when not engaged in conversation; otherwise his
mental status is normal. Motor, sensory, and cerebellar findings are normal. No asterixis is present.
The initial chest radiograph is interpreted to show biventricular enlargement and possible pulmonary
hypertension; the peripheral lung fields are clear.
1. What is the mechanism of obstructive sleep apnea?
2. Does obesity predispose to that condition?
3. What kind of changes in spirometry would you expect?