Question

CASE STUDY I

A 19-year-old female college student presents to the emergency department complaining

of chest tightness and dyspnea. She was cutting and trimming the lawn when these

symptoms developed. Rhinorrhea and tearing began soon after she went outside and

preceded the chest discomfort. Going inside did not relieve her symptoms.

During the physical examination, she said, “I have had asthma since childhood, and

my mother and brother also have asthma.” Her respiratory rate was 30 breaths per

minute, and she exhibited the use of accessory muscles of respiration. Breath sounds

were decreased, except for expiratory wheezes. Heart sounds were distant with

tachycardia, but regular.

Identify appropriate laboratory tests. Indicate what therapies might be initiated. What worsening signs and symptoms may manifest?

CASE STUDY II

Mr. S. is a retired 69-year-old county attorney who was on a buying trip with his wife

looking for old, classic cars in the high, mountainous country of Colorado when he

became extremely short of breath, much more than usual. His alarmed wife took him

to a multispecialty medical clinic for evaluation.

Upon admission, Mr. S. was restless and dyspneic. His history revealed a habit

of smoking two packs of cigarettes a day for 45 years (90 pack years). During the past

few years, Mr. S. noticed a cough each morning on arising. Recently, while working in

his flower garden, he had to stop at times to catch his breath. He stated, “Even while

I’m watching television, it is sometimes hard to breathe.”

On examination, the anteroposterior diameter of his chest was enlarged, and upon

percussion, his chest exhibited a hyperresonant sound. A chest radiograph was

taken, and pulmonary function tests were done. The chest radiograph revealed a

flat, low diaphragm with lung hyperinflation, but clear fields. Pulmonary function tests

showed decreased tidal volume and vital capacity, increased total lung capacity, and

prolonged forced expiratory volume.

Which pulmonary disease is exhibited by Mr. S.’s symptoms? Justify your answer.

Answer 1

1)

a) The appropriate laboratory tests are :-

• Allergy test done by skin test or blood test
• Test for eosinophils in blood
• Test for eosinophils in sputum

b) Therapies which might be initiated are :-

Long term control medications

• Inhaled corticosteroid such as Fluticasone, Budesonide, etc
• Oral leukotriene receptor antagonists such as Montelukast, Zafirlukast, etc
• Inhaled long acting beta agonists such as Salmeterol, Formoterol, etc
• Theophylline

Quick relief medications

• Oral and intravenous corticosteroids
• Inhaled short acting beta agonist
• Ipratropium

c) Worsening signs and symptoms :-

• Dyspnoea
• shortness of breath
• chest tightness
• very low systolic blood pressure
• oxygen saturation of less than 90%
• wheezing sounds

2)

Chronic obstructive pulmonary disease ( COPD ) is exhibited by Mr. S's symptoms.

It is because of the following characteristics :-

• History of cigarette smoking
• Dyspnoea
• Enlarged anteroposterior diameter of chest
• Hyper resonant sound heard upon chest percussion.
• Chest radiograph shows low, flat diaphragm with hyperinflated lungs
• Pulmonary function test shows decreased tidal volume and vital capacity, increased total lung capacity, and prolonged forced expiratory volume.

Answer 2

Allergy test done by skin test or blood tests Test for eosinophils in blood, tests for eosinophils in sputum