MONDAY, DECEMBER 4, 2000
10:30AM – 12:30PM
CHIEF COMPLAINT: "I'm short of breath; I can't stop coughing."
HISTORY: Mr. O'Connor is a 62-year-old auto mechanic who presents with progressive shortness of breath for the past several days. His problem began four days ago when "I got a cold." His "cold" consisted of a sore throat, rhinorrhea and myalgia. His job forces him to work in the cold and damp air. At first he just felt tired but later he developed a cough* and shortness of breath. Initially, the cough was dry but within 24 hours of onset, it produced abundant yellow-green sputum. He states, "I cough up a cup of this stuff every day." He didn't think much of the cough because he continually coughs during the winter of each year. His wife states that he "hacks and spits up" every morning when he gets up from bed.
The shortness of breath has worsened so that he can hardly speak now. He also has pain in the left side of his chest when he coughs. He becomes very tired after walking up a flight of stairs or during a coughing spell. He denies hemoptysis, night sweats, chills, and paroxysmal nocturnal dyspnea. However, he does complain of swelling of his ankles: "I've had this for more than a year."
Mr. O'Connor has been treated for high blood pressure, pneumonias and infections of his hands. He has been treated for similar episodes of coughing and shortness of breath during the past two years. Once he was hospitalized because "I was drinking too much and my pancreas acted up." A previous doctor gave him nitroglycerin. He smokes 1-2 packs of cigarettes per day and has done so for the past 35 years.
PHYSICAL EXAMINATION: The patient appears much older than he stated age of 62 years. He is a stocky man who appears haggard, tired and anxious. He speaks with difficulty, quickly becoming breathless. There is cyanosis which intensifies during coughing spells. Blood pressure is 146/82 mmHg. Apical heart rate is 96/minute and regular. Respiratory rate is 28/minute. Temperature is 100.2° F.
Examination of the head and neck reveals the use of accessory muscles during respiration. Jugular veins are dilated to 5 cm. with a prominent "a" wave.
Examination of the chest reveals use of accessory respiratory muscles. The anterior-posterior diameter of the chest is increased. Respiration rate is increased; respiration is regular and longer in expiration. Fremitus is decreased and the lung fields are hyperresonant (diffusely) with percussion. Percussion also reveals decreased excursion of the diaphragm (bilateral). Breath sounds are diminished bilaterally. Coarse crackles, rhonchi and expiratory wheezes are heard bilaterally. Most of these sounds clear with coughing.
Examination of the cardiovascular system reveals soft heart sounds: S2 is split and louder than S1. The P2 component seems louder than A2 and is heard best at the base of the heart. An S4 is heard best along the left lower sternal border. A murmur is not detected.
The abdomen is round but soft. Bowel sounds are not heard. The liver edge is round, slightly tender and palpable 2 cm. beneath the right costar margin in the mid-clavicular line. The prostate is enlarged and nodular on rectal exam.
Both feet show hallux valgus. There is pitting edema of the ankles.
LABORATORY TESTS:
The patient is first seen in the emergency room. The following data reflects the initial tests.
CBC:
Leukocyte count is 12,500/mm3; 58% neutrophils, 7% bands, 28% lymphocytes, 6% monocytes, 1% eosinophils. Hemoglobin = 19.8 g/dL; Hematocrit = 60%; Platelet count = 320,000/mm3.
Chemistry:
Glucose 112 mg/dL (non-fasting); BUN 16mg/dL, Creatinine 1 mg/dL;
Cholesterol 240 mg/dL; Aspartate aminotransferase (AST) 18 U/L, Alanine
aminotransferase (ALT) 32 U/L, Creatine kinase 72 U/L; Sodium 130 mEq/L,
Potassium 4.8 mEq/L; Chloride 90 mEq/L, Bicarbonate 33 mEq/L.
Arterial Blood Gases*:
pH 7.38, Pa O2 44 mmHg, Pa CO2 58 mmHg, HCO3 31 mEq/L.
Electrocardiogram: review attached sheet
Chest x-ray and sputum culture results are pending.
The patient is hospitalized. Spirometry is performed. The results are as follows:
FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17%
FVC = 1.7L, Predicted = 3.9 L, Percent of Predicted = 43%
FEV1/FVC = 29%
*Do not forget to use Seller’s Differential Diagnosis of Common Complaints when preparing for the case discussion. Also, refer to a standard book of physiology and one of the recommended texts of internal medicine (Cecil’s or Harrison) and handouts when analyzing diagnostic tests.
EDUCATIONAL OBJECTIVES
1. Define all unknown terms:
The students were told to use any source necessary to define all unknown terms in the case. The following texts are required: Medical dictionary, Robbins pathology text, Bates' physical diagnosis text and Seller’s Differential Diagnosis of Common Complaints. They are told to refer to Cecil’s or Harrison’s textbooks of medicine, if needed.
Site the first major, clinical problem (not the diagnosis).
Shortness of Breath (Dyspnea, Breathlessness)
3. Site the second major clinical problem (not the diagnosis)
Cough
Develop a broad differential diagnosis of the first major clinical problem using categories of diseases. Cite some examples from each category.
Pulmonary
Chronic Bronchitis
Pulmonary Emphysema
Asthma
Diffuse Interstitial Lung Disease
Pneumonia
Spontaneous Pneumothorax
Bronchiectasis
Acute Pulmonary Embolism
Pulmonary Hypertension
Cardiovascular
Congestive Heart Failure
Valvular Heart Disease (MS)
Cardiomyopathy
Anxiety with Hyperventilation
Obesity
Poor Physical Condition
Develop a broad differential diagnosis of the second major clinical problem using categories of diseases. Cite some examples from each category.
Infections
Viral Respiratory Tract Infections
Laryngitis
Pneumonia
Sinusitis
Tuberculosis
Pulmonary-Tracheo-bronchial Tree:
Asthma
Chronic Bronchitis
Bronchiectasis
Cystic Fibrosis
Allergies - Reactive Airway Disease
Lung Neoplasm
Cardiovascular
Congestive Heart Failure
MISC.
Postnasal Drip
Gastroesophageal Reflux
Irritation of the Tympanic Membrane
Psychogenic
Develop a limited or more specific differential diagnosis based upon the data given in the history and physical examination. In other words, what diseases have a higher probability of causing these clinical problems in this patient, especially when both are present? Why?
Chronic Bronchitis
Pulmonary Emphysema
Pulmonary Infection
Bronchiectasis
Pulmonary Neoplasm with Infection
Congestive Heart Failure
The symptoms seem to reflect primarily a pulmonary problem, although there also is a cardiac component. An elderly smoker with a chronic, productive cough presents with acute and significant dyspnea. He apparently experienced similar episodes in the past. Asthma, cystic fibrosis and allergic reactive bronchial disease can be ruled out. The physical findings in an elderly smoker supports chronic pulmonary pathology with heart failure. He seems to have an infection of the respiratory tract. However, does he have pneumonia? He has a fever but no chills. The patient is a likely candidate for developing a lung neoplasm because of his history. At this point in the case we cannot rule out this possibility. Physical signs point to pulmonary hypertension and right heart failure.
Explain the pathogenesis of the following clinical findings: cyanosis, tachypnea, fever, distended jugular veins, use of accessory muscles of respiration, increase A-P chest diameter and hyperresonant percussion, wheezing, loud S2 (P2), S4.
Cyanosis: poor ventilation causes decreased O2 (less O2 available to couple with hemoglobin); increased deoxygenated hemoglobin leads to cyanosis.
Tachypnea (28/min): Increased respiratory rate is an attempt to compensate for poor ventilation (decreased O2 , increased CO2). It is also compensation for air trapping with the patient breathing at a very high lung volume.
Fever: Reflects an acute infection superimposed on chronic bronchitis. Early pneumonia? Cytokines affect the thermoregulatory mechanism.
Distended jugular veins with "a" wave: Reflects elevated diastolic pressure and volume secondary to pulmonary hypertension. This finding coupled with a congested liver and pitting edema supports the diagnosis of acute cor pulmonale.
Use of accessory muscles of respiration: Respiration requires much more effort because of bronchial constriction and the need to breath at high lung volumes.
Increase in A-P chest diameter, hyperresonant percussion and decreased excursion of the diaphragm: Reflects hyperinflated lungs.
Wheezing, rhonchi, and crackles: Reflect narrowed bronchial lumina secondary to inflammation and mucous.
Changes in S2: Splitting is caused by delay in closure of pulmonary valve (pulmonary hypertension). P2 is accentuated with hypertension.
S4: Reflects forceful right atrial contraction/altered ventricular wall compliance. -- pulmonary hypertension.
8. What is you diagnosis? Why?
Chronic Obstructive Pulmonary Disease
Chronic Bronchitis with Superimposed Acute Infection
Emphysema
Secondary Pulmonary Hypertension
Cor Pulmonale -- Heart Failure
9. Describe the pathologic changes that you would expect to find in this patient.
Chronic Bronchitis: mucous within bronchial lumina; chronic inflammation of the bronchial wall, marked increase in the size of the mucous glands (increase in Reid Index), patches of squamous metaplasia. If the patient has pneumonia: exudate in alveoli and terminal bronchioles. Acute bronchitis: mucosa/submucosal edema, inflammatory cells (also in sputum).
Emphysema: destruction of alveoli creating large air spaces scattered throughout both lungs. Scattered small pulmonary arteries showing smooth muscle hypertrophy. Hyper-inflated lungs. Right ventricular/right atrial hypertrophy. Chronic passive congestion of the liver.
10. Correlate and explain the laboratory data. How does the data support your diagnosis?
The total white blood cell count is mildly increased, showing an early shift to the left. An acute bacterial infection superimposed on the chronic bronchitis may account for these findings.
The hemoglobin and hematocrit are increased. The erythrocytosis is secondary to the hypoxemia of chronic obstructive pulmonary disease. The patient is also a heavy smoker.
"Routine" chemistries show hypercholesterolemia. ALT is elevated, probably reflecting chronic passive congestion and mild hypoxia of the liver.
Arterial blood gases reveal a chronic respiratory acidosis with complete compensation. There is hypoxia and hypercapnia. The hypoxia is due to poor V/Q matching due to severe COPD.
Electrolytes: Hyponatremia is most likely due to CHF and atrial natriuretic factor, leading to relative dilution of sodium with fluid overload.
Determine the rate, rhythm and axis of the patient's electrocardiogram. Describe any abnormalities and correlate with the clinical problem.
The electrocardiogram show a rate of 80 BPM, normal sinus rhythm and right axis of (+137º); There is right ventricular hypertrophy with strain. The R is greater than S in lead V1 and the T wave is inverted in leads V1 - V2. Strain suggests ischemia during diastole in a hypertrophied wall. S waves are deep in the left precordial leads. There is borderline right atrial hypertrophy by voltage, especially noted in leads II and AVF.
Right ventricular hypertrophy is consistent with this patient's clinical problem. He has chronic obstructive pulmonary disease with secondary hypertension and consequent cor pulmonale. Make sure the students understand the pathogenesis of the atrial/ventricular hypertrophy. Also, they should understand the pathogenesis of secondary versus primary pulmonary hypertension.
12. Explain the significance, if any, of the results of spirometry.
The spirometry results are consistent with an obstructive pattern of pulmonary disease. The forced expiratory volume in 1 second LEV1 ) measures the average flow rate during the first second of the forced vital capacity (FVC) maneuver. FEV1 declines in direct proportion with clinical worsening of airway obstruction. It increases with successful treatment of airway obstruction. The percent of predicted FIVE for a normal patient should not slip below 80%.
The results of the chest x-ray and sputum culture are pending. What do you expect the results to be? What is the rationale, if any, for ordering a chest x-ray and sputum culture?
The chest x-ray is ordered to rule out pneumonia. The x-ray will show hyperinflation, low diaphragms and possibly increased bronchial markings. The transverse diameter of the heart may be increased.
A sputum culture would probably not be ordered routinely in COPD. The sputum culture would probably show mixed flora. A gram stain of the sputum might be a more helpful and economical first step. A sputum culture would be indicated if the first antibiotic failed to clear the infection. Probable organisms causing the pneumonia include Streptococcus pneumoniae, Hemophilus influenzae, Branhamella catarrhalis.
14. How would you treat this patient?
Treatment should include O2 to keep the saturation equal to or greater than 92%. Diuresis is indicated for edema, and digoxin therapy may be worthwhile, as well. In most cases an oral antibiotic will suffice to help with the purulent sputum: Common agents, Amoxicillin 500 mg TID x 7-lOd, Doxycycline 100 mg BID x 7-lOd, Trimethoprim/Sulfamethoxazole DS 1 BID x fed. If antibiotic resistance is a concern, second line agents (ie., more expensive) include Azithromycin, Ciprofloxacin, Augmentin. An ABG ought to be redone after O2 is begun to assess the effect of therapy on PO2 and PCO2. Also add B2-agonists and Ipratropium Bromide on a regular basis Q4-6 hours. Modest corticosteroid doses (prednisone 40-60 mg/d) with a rapid taper may also contribute to substantial improvement in breathlessness, wheezing, and even hyperthermia.
A 22 year old woman presents in the ER with dyspnea, cough, expiratory wheezing, use of accessory muscles for breathing. She has a history of allergies and similar attacks in the past. What is your diagnosis? How would you treat this patient?
Diagnosis: Bronchial Asthma
In the ER, asthma therapy should start with careful, rapid evaluation of the patient and pertinent physical findings: BP, pulses paradoxes, wheezing, diaphoresis, hypoxia, peak flow, ABG, etc. O2 should be started to keep saturation equal to or greater than 92%. Initial treatment should be B2agonists by MDI or nebulizers, and may include Ipratropium Bromide. If rapid response is not evident, consider adding Methylprednisolone 125 mg IV Q8° for 1-2d, followed by oral prednisone taper. Antibiotics are used only if infection is documented. The role of Theophylline has been controversial, but certainly can be used with caution. Injectable B-agonists may also have a role in the severely refractory patient.
Should the 22 year old woman be admitted to the hospital? For how long? Estimate the minimal cost of hospitalizing the patient for four days. How could you reduce the cost of caring for this patient? How long would a Medicare patient (with the same problem) be allowed to stay in the hospital?
The question is intended to stimulate the students to think about the cost of medical care. Please feel free to lead the students in a general discussion about costs. The estimated cost for hospitalizing this patient for four days, including laboratory studies (blood, x-ray, spirometry) is between five and six thousand dollars. Emphasize the need to be cost conscious when ordering tests, treatment or hospitalization. Medicare probably would allow for approximately two days of hospitalization.