Pulm Cases

A 20-year-old man presents to the emergency department 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 might have strained a chest wall muscle, but because the pain and dyspnoea 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 examination is normal.

pneumothorax

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 hypoxaemia 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.

ARDs

A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as a secretary in a high-tech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends, drinks socially, and has no history of drug use. Examination is notable for mild end-expiratory wheezing

ASTHMA

A 55-year-old female presents for the first time to the outpatient clinic, complaining of a gradual increase in cough and shortness of breath with wheezing for the past month. Her documented past medical history is notable only for seasonal allergic rhinitis. She notes that previously between attacks of her breathing difficulty, described as shortness of breath with wheezing, she would feel pretty normal. For the past year, she feels her breathing "isn't what it used to be," because episodes have become worse, and symptoms do not seem to fully resolve after attacks. She had been prescribed an albuterol inhaler that helps relieve the symptoms, but this has become a daily problem, and she has run out of her last prescription. She is also obese, and has been smoking 2 packs of cigarettes per day since the age of 16. No pets are in the home, and she denies having any prior or recent exposure to industrial chemicals.

ASTHMA

A 10-week-old boy presents to his physician's office in January because his mother feels his breathing is laboured. He was a full-term product of an uncomplicated pregnancy, labour, 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 38.0°C (100.4°F), his respiratory rate is 42 breaths per minute, and his oxyhaemoglobin saturation, measured by pulse oximetry, is 93% while breathing room air. He has a wet cough. His chest examination reveals mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally.

Acute bronchiolitis

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 examination reveals a temperature of 38.3°C (101°F), 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.

CAP

A 2½-year-old boy comes to your clinic for the first time with complaints of fever and increasing "wet" cough for 8 days. His mother reports that he has been diagnosed with asthma and has an albuterol inhaler to use for wheezing or cough. Since 6 months of age, he has had several similar episodes of "wet" cough and fever, which were diagnosed as bronchitis or pneumonia, and he would improve when treated with antibiotics and albuterol. However, over the past year, these episodes have become more frequent and the cough occurs almost daily now. Sometimes the mother sees him expectorate the sputum, which is thick and purulent. He has daily nasal congestion for which she uses saline and bulb suction in his nares. She is able to obtain some thick yellow discharge but the symptoms mainly improve when he is treated with antibiotics. He is not in daycare and has no tobacco exposure. She is concerned that his frequent illnesses are causing him to be "small for his age." The mother notes his stools are malodorous, and since starting him on potty-training she has observed that his stools float and sometimes appear to have drops of oil on them.

CF

Your examination reveals a moderately ill-appearing child whose height and weight are at the third percentile for age. His temperature is 101°F (38.3°C) and respiratory rate is 32 breaths/min. He is breathing with his mouth open. Over the upper lung fields, he has crackles and rhonchi and also a few expiratory wheezes over all lung fields. He has no heart murmur; S1 and S2 are normal. His fingers show clubbing. You obtain a chest radiograph that shows linear opacities in a parallel tram-track configuration in the upper lobes with some ring-shaped opacities

CF

A 52-year-old man presents to your office for an acute visit because of coughing and shortness of breath. He is well known to you because of multiple office visits in the past few years for similar reasons. He has a chronic "smoker's cough," but reports that in the past 2 days his cough has increased, his sputum has changed from white to green in color, and he has had to increase the frequency with which he uses his albuterol inhaler. He denies having a fever, chest pain, peripheral edema, or other symptoms. His medical history is significant for hypertension, peripheral vascular disease, and two hospitalizations for pneumonia in the past 5 years. He has a 60-pack-year history of smoking and continues to smoke two packs of cigarettes a day.

COPD

A 74-year-old woman and longtime smoker presents with fatigue and shortness of breath. She has not seen a physician for many years and says she has been basically healthy. On physical examination, she is found to be pale, mildly cachectic, and her lips are cyanotic. Her breath sounds are distant, although crackles can be heard in both lung bases. Her heart sounds are best heard in the epigastrium; a third heart sound is present. She has mild peripheral edema.

COPD

On examination, he is in moderate respiratory distress. His temperature is 98.4°F, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/min, his respiratory rate is 24 breaths/min, and he has an oxygen saturation of 94% on room air. His lung examination is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration. There are no signs of cyanosis. The remainder of his examination is normal. A chest x-ray done in your office shows an increased anteroposterior (AP) diameter and a flattened diaphragm, but otherwise he has clear lung fields.

COPD

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 ill contacts at work and did not receive the influenza vaccine this season.

Influenza

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 multi-drug-resistant pathogens. On admission to hospital, she has poor mental status and her bed is left with the head elevated to only a 5° angle. On hospital day 4, a CXR reveals a right lower lobe opacity.

HAP

A 65-year-old man presents with gradually progressive dyspnoea on exertion and a non-productive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnoea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus but does have a hx of rheumatoid arthritis. He is on no medications and has no environmental exposures to organic allergens such as mould. On examination, he has fine crackles audible over his lung bases bilaterally on late inspiration but no evidence of volume overload. He has clubbing of his fingers.

ILD

A 65-year-old man presents with a 2-month history of a new dry persistent cough, 4.5 kg unintentional weight loss, and hoarseness. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain, or haemoptysis. He expresses minimal shoulder and arm pain. Past medical history is significant for chronic obstructive pulmonary disease and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy was palpable on examination and breath sounds were diminished globally without focal wheezes or rales. ENT exam revealed ipsilateral ptosis and miosis. Urine analysis revealed Hyponatremia (serum Na+ <135 mmol/L) and concomitant hypo-osmolality (serum osmolality <280 mOsm/kg) indicating SIADH. CBC with dif all within normal limits.

Lung cancer

A 52-year-old woman developed acute shortness of breath 3 weeks after a hysterectomy. She denied leg pain or swelling. She has no chronic medical problems and takes no medications. Her pulse is 105 beats/min, respiratory rate is 20 breaths/min, and the rest of her examination is unremarkable. She had an elevated hemidiaphragm on chest X-ray (CXR).

PE

A 65-year-old man presents to the emergency department with acute onset of SOB of 30 minutes' duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination. His current vital signs reveal a fever of 38.0°C (100.4°F), heart rate 112 bpm, BP 95/65 mmHg, and an O2 saturation on room air of 91%.

PE

A 35 year alcoholic male with a history of seizures is admitted with a three week history of fever, generalized weakness, poor appetite, and cough productive of green, foul - smelling sputum. On physical examination, the temperature is 100.3 degrees P. pulse is 96 beats per minute, respiratory rate is 20 breaths per minute, and BP is 120/80 mm. There are many missing teeth with gingivitis and dental caries. He has rales and decreased breath sounds over the right base. Chest x-ray shows consolidation in the superior segment of the right lower lobe.

Pneumonia

A 29-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. CXR reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.

Sarcoidosis

A 38 year old black male consults you because of cough, sputum production and mild hemoptysis. He has had evening rise of temperature for the past one month and claims to have lost 30 lbs. over a three month period. On exam he appeared to be chronically ill and wasted. Cavernous breath sounds are heard over the right apex. Chest x-ray shows fluffy infiltrates and some amount of contraction of the right upper lobe. There is a cavity in the superior segment of the right upper lobe.

TB

A 60 year old male presents to the emergency room with a two month history of a 20 lb. weight loss, loss of appetite, low grade fever and night sweats. The patient has a chronic cough that is productive of yellow, blood-tinged sputum. The patient denies shaking chills, or chest pain. PMHx: Alcoholic liver disease, hospitalized 1 year ago with alcoholic hepatitis and alcohol withdrawal. (+)PPD (tuberculin skin test) one year ago not treated with prophylactic isoniazid because of the presence of hepatitis. Chronic obstructive pulmonary disease Meds: Albuterol and ipratropium inhaler Social: Drinks 6-12 beers / day, lives at the YMCA, has been homeless and lived in a shelter two years ago.

TB

Physical examination: Wasted malnourished patient, T: 37.5� C orally, HR 80, R 20, BP 110/60. Nodes: none. Chest: increased AP diameter Lungs: diminished breath sounds, rales in (R) upper lung field. CV: S,andS2NLnoS3/S./M. Abd: Scaphoid, liver span 13 cm firm, no spleen felt, no masses or ascites, nl bowel sounds. Ext: WNL. Neuro: WNL Laboratory: CBC - Hgb 11.0 gms WBL 15,000/mm3, 60 P. 35 L, 5 M, platelets 250,000/mm3. BUN, Creatinine, Lytes-WNL Liver function - WNL CXR: cavitary lesion (R) upper lobe with surrounding infiltrate, flat diaphragms. Sputum: many acid fast bacilli on smear

TB

A 20-year-old man from Mexico presents to the emergency room in a South Texas hospital with a persistent cough for 3 weeks, low-grade fever, and night sweats. His chest x-ray shows mediastinal and right hilar lymphadenopathy and right upper lobe consolidation

Tuberculosis

A 34-year-old man presents to his primary care physician with a 7-week history of cough that he describes as non-productive. 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 dyspnoea or hemoptysis. He is originally from the Philippines. He denies any history of TB or TB exposure. Physical examination reveals a thin, tired-appearing man but is otherwise unremarkable.

Tuberculosis

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 re-vascularisation. 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.

VAP

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 upper respiratory tract infection (URTI) are noted. Scattered wheezes are present diffusely on lung auscultation.

acute bronchitis

Deepak, 5 years of age, has been brought to his pediatrician by his mother for a dry hacking cough since the last 3-4 days. It all began with a cold, slight fever and sore throat 7-10 days back. This was followed by a watery nasal discharge which later became thicker and colored. On examination, the child was afebrile; pulse was 80/min, regular, General examination was normal, Examination of the chest showed scattered and bilateral rhonchi.

acute bronchitis

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, tachypnoeic, and has a fever of 38.8°C (102°F). His breath is foul smelling. Examination reveals egophony, decreased breath sounds, and dullness to percussion in the right lower lung field

aspiration pneumonia

A 12-month-old infant presents in winter months to the pediatrician with 2-day history of fever to 38.9°C (102°F), tachypnoea, conjunctival erythema, and nasal congestion with clear discharge. There has been an associated loss of appetite, with one episode of emesis. Influenza has been reported recently in the locality. The parents are concerned that the child was not vaccinated, due to a known history of egg allergy.

influenza

A 70-year-old women presents with slowly increasing dyspnoea. She cannot lie flat without feeling more short of breath. She has a history of HTN and osteoarthritis, and she has been taking NSAIDs with increasing frequency over the previous few months. On physical examination, she appears dyspneic at rest, her BP is 140/90 mm Hg, and pulse is 90 bpm. Her jugular venous pressure is elevated to the angle of the jaw. The left lung field is dull to percussion with decreased air entry basally. Crackles are heard in the right lung field and above the line of dullness on the left. Lower extremities have pitting edema to the knee.

pleural effusion

A 35-year-old woman presents with skin lesions around her nose, which are indurated plaques with discoloration. She also reports a red, moderately painful right eye with blurred vision and photophobia.

sarcoidosis