Hi it's Christmas! Can you help me with my case...just any ideas you have...I would really apprreciate it...

A case of a 60 year old male , with a body weight of 17.9 kg/m2 , brought in the emergency room for shortness of breath.


The patient is a known smoker for 30 pack years. He occasionally drinks. He is a known hypertensive and has congestive heart failure. He is already on maintenance medications for hypertension for 10 years. He claims to have a lung problem but could not recall the diagnosis, but is currently taking a combination of inhaled long acting bronchodilators and steroids. He is already a retired public transportation driver.


His condition started around 4 days prior to admission as cough which was productive with whitish sputum. There was no associated fever. Patient just took in some cough medications which afforded only temporary relief.


3 days prior to admission noted to have body malaise this time associated with slight shortness of breath, tried having some nebulizations at a local clinic which afforded only slight relief, thus continued having it every 4 hours.


2 days prior to admission condition still persisted thus decided to seek consult with a doctor in their locality, was given some antibiotics, cough medications and was told to continue his nebulization.


On the day of admission, noted his shortness of breath to increase in severity despite of the nebulizations, thus decided to be brought in the emergency room at a hospital in their locality.





On Physical examination, patient was examined to be in distress:


BP: 110/80 mm Hg


HR-120 beats/min


RR: 28 cycles /min


T: 36.9 C








Skin: cold with clammy sweats,


Neck: prominent sternocleidomastoid muscles, no lymphadenopathy, (+) neck vein engorgement,


HEENT: non icteric, pinkish palpebral conjunctiva, no tonsillophryngeal congestion, uvula in the middle, tonsils not enlarged,


Chest/Lungs: no deformities, barrel chested, no scars,





On physical examination, Mr. Winstone was found to have a body mass index of 27.9, his blood pressure was 133/90, pulse was 110, respiratory rate was 14, and his oxygen saturation was 88% on room air. The results of his head and neck exam were unremarkable, with no jugular venous distension noted. His chest excursions were symmetric with evidence of hyperinflation. Mr. Winstone's breath sounds were decreased throughout, and the expiratory phase was prolonged. His heart exam was notable for distant but otherwise normal heart sounds. The abdominal exam was unremarkable. There was no clubbing of his digits noted, but there was mild cyanosis and peripheral edema. His neurologic exam was nonfocal. Arterial blood gas drawn on room air revealed a pH of 7.39, PaO2 of 53, and PaCO2 of 44.


His pulmonary function results before bronchodilators (% predicted) were forced expiratory volume in 1 second (FEV1): 1.25 L (41%), forced vital capacity (FVC): 2.53 L (60%), and FEV1/FVC: 49. Post bronchodilator, his results were: FEV1: 1.29 L (42%) and FVC: 2.64 L (62%). His residual volume was 6.74 L (329%), total lung capacity: 9.45 L (150%) and his diffusing capacity was 6.96 L (25%).


Questions:


1. What is your impression?


2. Give at least 5 differential diagnosis?


3. What is your management?

Hi it's Christmas! Can you help me with my case...just any ideas you have...I would really apprreciate it...
He has an obstructive lung disease (decreased FEV1/FVC), along with what could be an exacerbation of his CHF, given his edema.





The differential for obstructive lung diseases is asthma, COPD, and something physically obstructing the airway (like he choked on something or a tumor was compressing a main airway). It sounds like what he has is COPD, more on the emphysema side.





He needs to get his oxygen up. He's probably in V/Q mismatch (with maybe some shunt) so supplemental oxygen would get his sats up. If his respiratory muscles are too exhausted or if the cannula or face mask isn't working, he may need mechanical ventilation. And obviously once he's out of the acute problem, he needs to stop smoking.
Reply:ok, this sounds like you're a nursing student looking for answers to a homework assignment or exam, am I right?





first of all I dont think you should be asking all this here, but I do suggest that you open up your Med-surg book and/or Pathophysiology and look under respiratory problems such as COPD, Emphysema, Bronchitis, etc. also since the guy has HTN then look up left-sided heart failure maybe that can help, but don't forget to do the work yourself, you'll feel better afterwards at your accomplishment.
Reply:Contradiction: first part of PE has + neck vein engorgement and later states no JVD....but would think CHF here along with exacerbation of COPD. He is very hypoxic and has hypoxemia as well.


Differential: acute coronary event (MI); pulmonary embolus, COPD exacerbation with peripheral edema; ? mitral regurg (?murmur); acute renal failure; decompensated heart failure due to infectious etiology.


Treatment: Careful oxygen (don't know if he is a CO2 retainer fully); diuresis, nitrates, short acting nebulizer (albuterol + atrovent), EKG, CXR, cardiac enzymes, chem panel, pulse oximetry ICU admit
Reply:Asthmatics 12 times more likely to develop Chronic Lung Disease (COPD)





July 2004: A study has revealed that Asthmatics are 12 times more likely to develop chronic lung disease than non-asthmatics. The study, carried out at the University of Arizona, took over 20 years to complete and found that the risk of developing COPD (Chronic Obstructive Pulmonary Disease) for an asthmatic is twelve times higher than someone who does not suffer from asthma.





The researchers said that it is crucial to understand the link between COPD and Asthma. This could eventually help us detect the condition earlier and offer better treatment.





Such conditions as chronic bronchitis and emphysema come under the term COPD.





Experts say that asthma does not cause permanent lung damage.





Study leader was Dr. Graciela Silva, Arizona University, USA. Dr. Silva said to the Daily Mail 'For many years, asthma and COPD have been regarded as distinct conditions, with separate clinical courses. However, over time, the two diseases may develop features that are quite similar. Our study shows a strong link between asthma diagnosis and the development of COPD, which suggest they may share a common background.'

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