Pulmonology Vignettes
Chronic Bronchitis (exacerbation)
Common Vignette 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.
Pulmonary Fibrosis
Common Vignette 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.
Foreign Body Aspiration
Common Vignette A 3-year-old boy was playing with colorful interlocking plastic bricks when he suddenly started coughing and gagging. The child subsequently developed a high-pitched sound and his breathing became labored. The child's caregiver called the paramedics, but while waiting for the ambulance the child's breathing slowed and he became unconscious.
Pulmonary Artery Hypertension
Common Vignette 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.
Hypersensitivity Pneumonitis
Common Vignette A 38-year-old man presents with fever of 101.2°F (38.5ºC), chills, myalgias, nonproductive cough, and dyspnea. Other than tachypnea, tachycardia, and bibasilar rales, the rest of the physical exam is normal. He reports that this happens almost every month the day after he cleans out the bird cages in which he keeps the pigeons that he breeds and races.
Asthma
Common Vignette A 3-year-old girl presents with a history of episodes of wheeze and troublesome cough over the past 2 years. These episodes are more common through the winter months. On 2 occasions she has been given oral corticosteroids because of severe wheeze, which was relatively unresponsive to beta-2 agonist given via MDI. In the past 6 months she has had monthly episodes of wheezing with shortness of breath, and 2 of these have resulted in need for frequent beta-2 agonist. At present she is using beta-2 agonist as required, but has used inhaled corticosteroids during the attacks in the past. Between these episodes she is well, although her mother has noted some wheeze after vigorous playing. Her father has asthma and the child herself has eczema.
Pneumonia (pneumocystis jirovecii)
Common Vignette 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.
Emphysema (alpha-1 antitrypsin deficiency)
Common Vignette 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.
Bronchiolitis
Common Vignette 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.
Mycoplasma Pneumonia
Common Vignette 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 (38.3ºC) and has mild crackles in the right lower lung field.
Asthma
Common Vignette 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.
Tuberculosis
Common Vignette 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.
Viral Pneumonia (SARS)
Common Vignette A 34-year-old man presents to the emergency department with a 3-day history of fever, chills, headache, dry cough, myalgia, dyspnea, and diarrhea. He reports that he returned from an area with a recently documented cluster of SARS cases 5 days prior to the onset of his symptoms. He is hypoxic, and the initial chest x-ray reveals multifocal bilateral infiltrates. Laboratory findings show a moderate leukopenia (in particular, lymphopenia) and thrombocytopenia along with elevated creatinine kinase, lactate dehydrogenase, and aminotransferase levels. He is isolated in a negative pressure chamber and gradually improves over the next 4 days. On day 5, the fever and diarrhea relapse and subsequent chest x-rays reveal new infiltrations. The patient develops respiratory failure and hemodynamic instability. He is transferred to the ICU, where mechanical ventilation is initiated. As clinical deterioration continues, he progresses to acute respiratory distress syndrome (ARDS) and dies 6 days later.
Acute Bronchitis
Common Vignette 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.
Laryngeal Cancer
Common Vignette A 45-year-old man presents with a 3-month history of sore throat and painless, enlarging, left-sided neck mass. Two courses of antibiotics and a trial of corticosteroids did not clear the sore throat and mass. He also reports dysphagia with solids and worsening odynophagia (painful swallowing), and a 7-kg weight loss over the last 2 months. His past medical history is significant for hypertension and COPD, both well controlled with medication. He has a 50-pack-year smoking history. Physical exam finds a 2-cm, firm, mobile, and nontender mass anterior to the sternocleidomastoid muscle in the patient's mid left cervical lymph node chain. There is no overlying erythema or induration. The oral cavity and oropharynx are normal, as are the cranial nerves on exam. Breath sounds are clear without stridor or stertor. Flexible fiberoptic laryngoscopy demonstrates a thickened epiglottis with an ulcerating and necrotic mass on its laryngeal surface that extends to involve both aryepiglottic folds and the left true and false vocal cords. The true vocal cords are mobile bilaterally and appear normal.
Community Acquired Pneumonia
Common Vignette 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.
Bronchiectasis
Common Vignette 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.
Laryngeal Cancer
Common Vignette A 57-year-old man presents with a 6-month history of hoarseness. He has a reactive airway disease diagnosis and is treated for asthma. Over the last week he has noted progressive difficulty breathing. He also has otalgia, dysphagia, odynophagia (painful swallowing), and a 9-kg weight loss. He has an 80-pack-year tobacco history and drinks 8 beers per day. On physical exam, oral cavity and oropharynx are within normal limits. Neck exam demonstrates a right-sided mass that is firm and fixed. Cranial nerve exam is normal. There is mild biphasic stridor with deep inspiration and expiration, but the patient has no increased work of breathing at rest, and breath sounds are clear. Flexible fiberoptic laryngoscopy demonstrates a necrotic, ulcerating mass involving the right true and false vocal cords, and extension onto the epiglottis and aryepiglottic folds. The right true vocal cord is immobile. The glottic airway is partially obstructed.
Viral Pneumonia (RSV)
Common Vignette A 6-month-old, previously well female infant presents in midwinter with a 3-day history of rhinorrhea, cough, and malaise. Several other school-age children in the home also have respiratory symptoms. The infant has a temperature of 101.2°F (38.5°C), respiratory rate of 70 breaths per minute, and oxygen saturation of 85% on room air. She has nasal flaring, head bobbing, and suprasternal and intercostal retractions. Auscultation reveals bilateral wheeze with prolonged expiration. The infant's work of breathing improves mildly with nasal suctioning, and her oxygenation improves with warm, humidified oxygen through nasal cannula, but there is no improvement with nebulized albuterol.
Acute Respiratory Distress Syndrome (ARDS)
Common Vignette 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.
Aspiration (acute)
Common Vignette A 62-year-old woman with SLE undergoes a head MRI for acute mental status changes suggesting lupus cerebritis. The patient has been taking prednisone 40 mg each day for several months. She has a diagnosis of GERD, for which she takes proton-pump inhibitors twice a day. During the imaging study in the supine position, the patient vomits and aspirates gastric contents consisting of yellowish-greenish fluid. Severe respiratory distress and hypoxemia develop, and she requires endotracheal intubation, mechanical ventilation, and admission to the ICU. Physical exam reveals bilateral crackles and wheezes.
Pulmonary Embolism
Common Vignette 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 100.4°F (38.0°C), heart rate 112 bpm, BP 95/65 mmHg, and an O2 saturation on room air of 91%.
Non-Small Cell Lung Cancer
Common Vignette 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.
Pulmonary Fibrosis
Common Vignette 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.
Pneumoconiosis
Common Vignette 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.
Pneumonia (pneumocystis jirovecii)
Common Vignette A 45-year-old woman with a history of Wegener granulomatosis, treated for 6 months with cyclophosphamide and prednisone, presents with 1 week of cough, shortness of breath, and fevers. She is tachypneic and has a pulse oximetry of 80% on room air. She is in a moderate amount of respiratory distress and has some diffuse rales in her lungs.
Hospital Acquired Pneumonia
Common Vignette 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.
Emphysema (COPD)
Common Vignette 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.
Emphysema (COPD)
Common Vignette 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.
Pulmonary Edema (pleural effusion)
Common Vignette A 70-year-old woman presents with slowly increasing dyspnea. She cannot lie flat without feeling more short of breath. She has a history of hypertension 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 mmHg, 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 quiet breath sounds 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.
Pneumoconiosis
Common Vignette A 76-year-old retired foundry 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.
Pulmonary Edema (pleural effusion)
Common Vignette A thin 56-year-old man has pain in his right chest with deep inspiration and is short of breath at rest and with exertion. He has felt feverish for 1 week and complains of a productive cough with foul-smelling and -tasting sputum. He regularly drinks alcohol and was inebriated and vomited 1 week before his symptoms began. Past medical history and family history are unremarkable. On physical examination, he is febrile at 100.7°F (38°C), BP is 130/78 mmHg, and pulse is 110 bpm. He looks ill and has poor dental hygiene. Breath sounds are quiet over the right lower lobe with dullness to percussion and decreased tactile fremitus in the lower half of the lung field.
Asthma
Common Vignette An 8-year-old boy presents with intermittent wheeze and cough, and with a history of asthma. Over recent months he has had problems with nighttime wheeze and shortness of breath. He is waking at least 3 or 4 nights per week since recovering from an upper respiratory infection. He requires his beta-2 agonist metered dose inhaler (MDI) to enable him to get back to sleep. He has also noted more problems with wheeze and shortness of breath on minimal playing at school. His general practitioner has tried cromolyn sodium and a leukotriene receptor antagonist in the past, but currently he is managed with beta-2 agonist as required. He now needs a new beta-2 agonist MDI every 2 to 3 weeks.
Foreign Body Aspiration
Common Vignette An 82-year-old man suddenly choked while eating loquat fruits at home. The patient subsequently presented to the ER with a severe cough. His physical exam was normal except for localized wheezing in the right lower lung field, best heard anteriorly. There were no focal neurologic deficits and no significant past medical history. However, the patient's wife stated that he often coughed while eating.
Hospital Acquired Pneumonia
Common Vignette 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. On hospital day 4, a CXR reveals a right lower lobe opacity.
