Pulm Vignettes
A 76-year-old retired foundry(rocks or steele) worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack/year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. He has noticed he wheezes when he has an URI, and his doctor once prescribed him an inhaler. He is also bothered by joint swelling and stiffness. Lung auscultation is normal.
(This case is a common clinical presentation of silicosis or coal workers' pneumoconiosis.) Pneumoconiosis
A 27-year-old woman with a history of moderate persistent asthma presents to the emergency room with progressive worsening of shortness of breath, wheezing, and cough over 3 days. She reports prior exposure to a person who had a runny nose and a hacking cough. She did not receive significant relief from her rescue inhaler with worsening symptoms, despite increased use. She has been compliant with her maintenance asthma regimen, which consists of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and albuterol as rescue therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.
Acute Asthma Exacerbation in Adults Consider adding mast cell stabilizer such as cromolyn or montelukast
A 5-year-old girl presents to the emergency department with a 2-day history of coryza and cough with intermittent low-grade fever. She developed an audible wheeze and respiratory distress that was initially responsive to albuterol via a pressurized metered-dose inhaler and small-volume spacer. However, symptoms have recurred within 2 hours of albuterol administration. The patient has had a number of episodes of wheeze and dyspnea over a 2-year period; these were more common during the winter months. She required prednisone on 2 occasions to treat severe wheeze. On exam, she is in visible respiratory distress with a respiratory rate of 40 breaths/minute and has accompanying accessory muscle use. Her oxygen saturations are 92% in room air, and on auscultation of her chest there is widespread polyphonic wheeze and equal air entry. She has an audible moist cough.
Acute Asthma Exacerbation in Children
Delete this ??????????????????????A 12-year-old girl presents to the emergency department with a 12-hour history of a troublesome cough followed by wheezing and increasing breathlessness unresponsive to inhaled albuterol. She has had troublesome asthma since the age of 18 months. Over the past few months, her asthma has been managed with fluticasone/salmeterol via a pressurized metered-dose inhaler and large-volume spacer, and an albuterol inhaler, which is used as needed. She has been poorly compliant with her preventive medication, adhering only when symptomatic. On exam, she is extremely distressed. She appears slightly cyanosed on air, and pulse oximetry shows an oxygen saturation of 84%. She has marked use of accessory muscles and is unable to speak in sentences but can say single words. She has marked pulsus paradoxus on palpation. On auscultation of the chest there is widespread expiratory wheeze but equal air entry.
Acute Asthma Exacerbation in Children
A 34-year-old woman with no known underlying lung disease has had a 12-day history of cough that has become productive of sputum. Initially she was not short of breath, but now she becomes short of breath with exertion. She initially had nasal congestion and a mild sore throat, but now her symptoms are all related to a productive cough without paroxysms. She denies any sick contacts. On physical examination she is not in respiratory distress and is afebrile with normal vital signs. No signs of URI are noted. Scattered wheezes are present diffusely on lung auscultation.
Acute Bronchitis
A 67-year-old woman with a history of COPD presents with 3 days of worsening dyspnea and increased frequency of coughing. Her cough is now productive of green, purulent sputum. The patient has a 100-pack-year history of smoking. She has had intermittent, low-grade fever of 100°F (37.7°C) for the past 3 days and her appetite is poor. She has required increased use of rescue bronchodilator therapy in addition to her maintenance medications to control symptoms.
Acute COPD Exacerbation
A 60-year-old man presents with acute onset of SOB, fever, and cough. CXR shows a right lower lobe infiltrate, and sputum has gram-positive diplococci. He is given IV antibiotics but his respiratory status declines over 24 hours. He becomes hypotensive and is transferred to the ICU. He is intubated for hypoxemia and requires vasopressors for septic shock despite adequate volume resuscitation. He requires high levels of inspired oxygen (FiO2) and PEEP on the ventilator to keep his oxygen saturation >90%. Repeat CXR shows bilateral alveolar infiltrates, and his PaO2/FiO2 ratio is 109
Acute Respiratory Distress Syndrome Tie this to atelectasis
A 39-year-old man presents for the third time in 2 years (to different physicians each time) for evaluation of an intermittent productive cough and increasing dyspnea on exertion. He has a 15 pack-year smoking history, reports thick, yellow phlegm at times, and describes having trouble keeping up when playing with his children. His medical history reveals mild intermittent asthma controlled with an albuterol inhaler. His symptoms have persisted despite stopping smoking, and his asthma exacerbations have increased in frequency, with some attacks being unresponsive to albuterol. Physical exam reveals a generally healthy-looking male. During the exam he experiences coughing with subsequent wheezing on auscultation and a long expiratory phase. Cardiac exam is normal. Spirometry demonstrates an FEV1 of 40% of his predicted value.
Alpha-1 Antitrypsin Deficiency (Emphysema) this dude is young!!!!! Treatment
A 55-year-old factory maintenance worker falls at work. A CXR is performed to evaluate the patient for a possible broken rib. Bilateral pleural thickening is seen on CXR. Further history indicates he is very active without any respiratory symptoms. He smokes 20 cigarettes a day. There is no family history of lung disease. He does not take any respiratory medicine.
Asbestosis
A 67-year-old retired construction worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack-year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. With colds he has noticed wheezing and his doctor once prescribed an inhaler.
Asbestosis
A 75-year-old man presents with an acute stroke including right-sided paralysis and altered mental status. Two days after admission, he notes cough and right-sided pleuritic chest pain. He is tachycardic, tachypneic, and has a fever of 102°F (38.8°C). His breath is foul smelling. Examination reveals egophony, decreased breath sounds, and dullness to percussion in the right lower lung field
Aspiration Pneumonia Tx: pip tazo, ceftriax
A 25-year-old woman presents with shortness of breath. She reported that in high school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.
Asthma (Adult)
A 20-year-old college student presents with a 3-day history of cough, fever, malaise and headache. On examination he is febrile to 101°F and he has crackles in the right lower lung field.
Atypical Pneumonia tx- azithromycin MC organism is mycoplasm
A 55-year-old woman presents for evaluation of a chronic cough, productive of thick, yellow sputum that sometimes becomes blood-tinged. She has experienced recurrent episodes of fever associated with pleuritic chest pain. She states that she is embarrassed by the persistent, intractable nature of her cough and has been prescribed multiple courses of antibiotics. Over the last 5 years, she has developed shortness of breath with exertion. Her past medical history is significant for pneumonia as a child and sinus polyps during adulthood for which she has had surgery.
Bronchiectasis Abx: Cephtriaxone bronchodilator, aintinflammatory
A 10-week-old boy presents to his physician's office in January because his mother feels his breathing is labored. He was a full-term product of an uncomplicated pregnancy, labor, and delivery. His mother smoked during pregnancy and continues to do so. The family history is negative for asthma or allergy. He developed rhinitis and a tactile fever 3 days prior to presentation. Over the next few days he developed increasing cough, increased work of breathing, and decreased oral intake. On examination, his temperature is 100.4°F (38.0°C), his respiratory rate is 42 breaths per minute, and his oxyhemoglobin saturation, measured by pulse oximetry, is 93% while breathing room air. He has a wet cough. His chest exam reveals mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally.
Bronchiolitis Tx with supportive care O2 n hydrate Steriods if they are really bad
A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.
COPD
A 66-year-old man with a smoking history of 1 pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting edema.
COPD O2 Bronchiodilator Steroids
A 15-year-old boy presents with a 2-week history of headache and nonproductive cough. On physical examination he is a well-developed but ill-appearing young man in mild respiratory distress. His temperature is 101.8°F (38.8°C) and his respiratory rate is 22 breaths per minute. Auscultation of the chest reveals scattered crackles and wheezes over both lungs with dullness at the right base.
Chlamydia Pneumoniae Infection (2nd most common atypical)
A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical exam reveals a temperature of 101°F (38.3°C), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. CXR reveals a left lower lobe infiltrate.
Community - Acquired Pneumonia
A 6-year-old boy with a medical history significant for mild persistent asthma is brought to the clinic by his mother with a history of a 5-day cough. His mother reports that the child's fever continues to be elevated despite acetaminophen therapy. He has missed school for the past 3 days and he has a classmate sick with pneumonia. The mother reports that the appetite is good for the child. His cough produced yellowish sputum at home. His vitals at the clinic are: respiratory rate 19 breaths/min, heart rate 80 beats/min, and temperature 101.6°F (38.7°C). He appears in no respiratory distress. His lung examination reveals bilateral rales and occasional wheeze. CXR reveals lobar infiltrates without pleural effusions.
Community - Acquired Pneumonia Azithromycin(doesn't need to be hit hard)
A 2-year-old boy is brought to the emergency room by his parents in the middle of the night. He has had mild symptoms of an upper respiratory infection for 48 hours, awoke with a sudden onset of seal-like barky cough and has had inspiratory stridor when crying. The stridor disappeared at rest, but the seal-like barky cough has persisted.
Croup Treatment: Epinephrine and oxygen
A 1-year-old child presents with failure to thrive. By history, the child was born at the 50th percentile for weight, but has crossed multiple percentile lines despite having a ravenous appetite. The child has more bowel movements per day than other children of the same age, and the stools often look shiny and have an unusually foul smell. In addition, the child has been treated with multiple courses of antibiotics for a persistent, wet cough. On measurement, the child is small for age, with weight and length below the third percentile.
Cystic Fibrosis Tx pneumonia with abx(pipericilin tazobactam) tx cystic fibrosis with protease >>>worried about pseudomonas<<<
A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. There is a history of hypertension, mild CHF, and recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins in the leg are more dilated on the right foot and the right leg is slightly redder than the left. There is some tenderness on palpation in the popliteal fossa behind the knee.
Deep Vein Thrombosis lovanox and warfarin
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A 4-year-old boy presents to the emergency department with complaints of dysphagia, fever, drooling, and muffled voice. Symptoms have progressively worsened over the course of the day. He is toxic-appearing, and leans forward while sitting on his mother's lap. He is drooling, and speaks with a muffled "hot potato" voice. The parents deny trauma or evidence of foreign body ingestion. They have no recollection of the child receiving a Haemophilus influenzae type B (Hib) vaccine.
Epiglottitis Tx w/ Abx(amoxicillin)
A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. PFTs are performed and show restriction rather than obstruction, and impaired diffusing capacity for carbon monoxide. A follow-up CXR shows prominent bibasilar interstitial markings.
Idiopathic Pulmonary Fibrosis
A 55-year-old man with a history of peripheral vascular disease, who presents with a complaint of a left foot ulcer and pain when walking short distances, is found to have a popliteal stenosis and admitted for revascularization. Four days after admission, on postoperative day 3, he develops SOB, hypoxia, and a productive cough. Auscultation of his chest reveals decreased breath sounds at the lower aspect of the right side of his chest. His morning leukocyte count is slightly higher than the day before, at 11,000 cells/mL^3. An anterior-posterior bedside CXR reveals right lower lobe opacity.
Hospital- Acquired Pneumonia piperacillin tazobactam and levofloxacin
An 88-year-old female resident of a nursing home, who typically does not present to the acute care hospital, has frequent UTIs that are managed by the nursing home physician. In the nursing home, she develops a UTI due to multidrug-resistant pathogens. On admission to the hospital, she has poor mental status and her bed is left with the head elevated to only a 5° angle. Within 24 hours a CXR reveals right lower lobe opacity.
Hospital- Acquired Pneumonia TX: vanco and ceftriaxone laying flat/AMS risk for aspiration pneumonia-->lung abcess
A 36-year-old woman presents with a 6-month history of gradually progressive dyspnea on exertion and fatigue. On physical exam, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation. Her cardiac exam shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border.
Idiopathic Pulmonary Arterial Hypertension prostaglandins (epoprostanol )
A 65-year-old man presents with gradually progressive dyspnea on exertion and a nonproductive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He is on no medications and has no environmental exposures to organic allergens such as mold. On exam he has fine crackles audible over his lung bases bilaterally but no evidence of volume overload. He has clubbing of his fingers.
Idiopathic Pulmonary Fibrosis Protaglandins
why??? A 42-year-old man presents with fever, myalgia, and headache for 24 hours. He denies any SOB or cough. He has a history of hypertension and diabetes type 2 and works in construction.
Legionella Infection
A 55-year-old woman with a history of tobacco use (40 pack-years) presents with fever, dyspnea, and a productive cough of thick yellow sputum for 3 days. She also reports a headache with some nausea and vomiting for the last 24 hours. She travels frequently, and was most recently attending a conference in Boston, MA, for 5 days, where she stayed in the large hotel where the conference was being held.
Legionella Infection azithromycin
Delete this??? A 20-year-old college student presents with a 3-day history of cough, fever, malaise and headache. On examination he is febrile to 101°F and he has crackles in the right lower lung field.
Mycoplasma Pneumonia
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnea, sore throat, rhinorrhea, chest pain, or hemoptysis. Medical history is significant for COPD and hypertension. Family history is noncontributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or rales.
Non-Small Cell Lung Cancer
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnea, sore throat, rhinorrhea, chest pain, or hemoptysis. Medical history is significant for COPD and hypertension. Family history is noncontributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or rales.
Non-Small Cell Lung Cancer Weight-loss in old smoker = lung cancer(dittmer pearl)
A 40-year-old high school teacher presents with cold symptoms lasting 3 weeks. She has low-grade fever, fatigue, and paroxysms of coughing. Her cold symptoms were initially mild but gradually increased in severity, resulting in her presentation to the emergency room. OTC cold medications have not provided relief.
Pertussis
A 35-year-old man who works machining beryllium-copper alloy for the electronics industry is concerned about the possibility of adverse health effects from beryllium, which is a component of the metal he is machining. He has heard about a blood test that can be used for diagnosing beryllium disease. He is not sure if he has had some increased shortness of breath with exercise. He has never smoked cigarettes. He has no personal or family history of allergies or asthma. Lung auscultation is normal. (This case is a common clinical presentation of chronic beryllium disease.)
Pneumoconiosis
A 34-year-old man with a history of sex with men presents with 3 weeks of worsening dyspnea associated with fevers and a nonproductive cough. He is tachycardic and tachypneic, and has a temperature of 100.5°F (38.1°C). His pulse oximetry is 86% on room air. He appears thin and in moderate respiratory distress. His lung examination is unremarkable.
Pneumocystis Pneumonia Abx: trimethoprim/sulfamethoxazole corticosterioids
A 20-year-old man presents to the emergency room with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he may have strained a chest wall muscle but, because the pain and dyspnea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular exam is normal.
Pneumothorax
A 65-year-old patient with COPD presents to the emergency room with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the color or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.
Pneumothorax
A 34-year-old man presents to his primary care physician with a 7-week history of cough that he describes as nonproductive. He has had a poor appetite during this time and notes that his clothes are loose on him. He has felt febrile at times, but has not measured his temperature. He denies dyspnea or hemoptysis. He is originally from the Philippines and has lived in the US for 10 years. He denies any history of TB or TB exposure. Physical examination reveals a thin, tired-appearing man but is otherwise unremarkable.
Pulmonary Tuberculosis
A 30-year-old woman presents in January with 2-day history of fever, cough, headache, and generalized weakness. She was in her usual state of health before an abrupt onset of these symptoms. A few viral illnesses have affected her during the current winter, but not to this severity. She reports sick contacts at work and did not receive the seasonal influenza vaccine this season.
Seasonal Influenza Self limiting, oseltamivir Prego know: zanamivir
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