Case Critique 1: Lung Disease

SKILLS - Students should demonstrate specific skills, including:

  1. History-taking: Students should be able to obtain, document, and present an age-appropriate medical history, including duration and severity of shortness of breath, sputum production, cough, wheezing, hemoptysis, fever, abnormal nocturnal/diurnal sleep patterns, patient's occupational history, including current and past exposures, environmental, smoking (active and passive).
  2. Physical Exam: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including accurate assessment of the use of accessory muscles for breathing, accurate determination of pulsus paradox, and accurate recognition of abnormal breath sounds.
  3. Differential Diagnosis: Students should be able to generate a differential diagnosis recognizing specific history and physical exam findings that confirm or refute a diagnosis of asthma, chronic bronchitis, or emphysema.
  4. Laboratory Interpretation: Students should be able to recommend when to order and how to interpret a chest x-ray, spirometry, arterial blood gases, sputum gram stain, and pulse oximetry in the evaluation of patients suffering from obstructive airways disease.
  5. Communication Skills: Students should be able to communicate the diagnosis, prognosis, and treatment plan of the disease to patients and their families.

A 65 year old male was admitted with the chief complaint of increased shortness of breath and a cough productive of yellow sputum for three weeks. The patient states that he has had "bronchitis" and "asthma" for several years resulting in a chronic cough, usually productive of one to two tablespoonfuls of mucoid sputum daily, as well as persistent mild to moderate dyspnea on exertion. Overall, while he describes having “some good days and some bad days”, he always experiences some dyspnea on exertion. He uses a beta-agonist inhaler occasionally, with some mild relief of dyspnea, and is prescribed antibiotics once or twice a year. For the past several days, however, his inhalers have failed to relieve his dyspnea, he has been sleeping poorly, and he complains of having increasing difficulty coughing up his sputum. He denies fever, night sweats, or weight loss. He admits to a 100 pack year smoking history, although he has recently cut down to 1/2 pack per day.

1 What can you say about this patient's underlying lung disease?

a. What are the clinical criteria for chronic bronchitis?

b. Do you accept this patient's diagnosis of "asthma"?

c. Compare the classic characteristics of patients suffering from emphysema and chronic bronchitis.

2  What is the significance of the change in sputum color?

3  What probably happened to this man to necessitate this hospitalization? Could this possibly have been prevented? Discuss the use of antibiotics on an out-patient basis in patients with COPD?

On physical examination, the patient was a cachectic, anxious male in acute respiratory distress with rapid respirations, marked supraclavicular and intercostal retractions, using his accessory muscles to breath. T = 98 o ; P = 85; BP = 120/85; RR = 30. Lips were cyanotic. Neck veins were distended to the mandible but collapsed with inspiration. Chest exam revealed limited expansion, increased A-P diameter, hyperresonance and a fixed diaphragm on percussion, marked inspiratory and expiratory wheezing, and a prolonged expiratory phase. Heart sounds were distant with a regular rhythm. There was no clubbing or edema.

4  Why is this patient cachectic?

5  What is responsible for the oscillation in neck vein distention?

6. Discuss the expected physical examination findings in COPD.

7. Do you think the hemoglobin of 16.5 is of any significance?

6  Discuss the data for and against the use of corticosteroids in patients with COPD.

7  Describe a step-wise approach to the medical management of outpatients with COPD.

8  Which patients should be screened for alpha-1 antitrypsin deficiency?