Pulm Patient Cases

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Graham has idiopathic pulmonary fibrosis, a condition of collagen deposition on the lungs that is unexplained. Fibrosis, however, can also be caused by many substances: e.g. radiation tx over 40 Gy (radiation fibrosis) and different types of drugs, e.g. amiodarone, cisplatin, and methotrexate (drug-induced fibrosis). When initial tests
come back negative and with the honeycombing sign, you may choose to perform spirometry to examine Grahams FEV1 and FVC to determine if he has restrictive lung disease. There is no cure so tx is supportive. You encourage Graham to stop smoking and you refer him for pulmonary rehab. You can provide supplemental oxygen PRN and you recommend that he stays current on his vaccinations (e.g. pneumococcal and flu) to avoid complications. If he is a good candidate, you could also recommend Graham for lung transplantation.

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10. Karen is a 4 YO female who presents w/ runny nose, sneezing, and fever for the past 3 days. Her father says she hasn’t been eating as much as usual and seemed to be breathing hard, so he’s getting worried about her. Karen has a hx of well-controlled asthma. Vitals are RR 38, temp 98.8 F, BP 100/60, HR 100, O2 86%. On PE, you observe nasal discharge, a reddened pharynx, and expiratory wheezing. You order an x- ray and see no consolidation or costophrenic blunting, but do observe increased bronchial markings. What is your dx and tx for Karen? Do you admit?

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12. Jordan has asthma, a chronic, reversible, obstructive lung condition. His mother misinterpreted his dyspnea during practice for fatigue. His asthma seems to be largely triggered by exercise, but given his additional resting episodes with Snuggles, you want to give him more than a rescue/relief inhaler. Before rxing anything, you want to perform a spirometry test. You ask Jordan to run in place while you get the equipment so you can get a more accurate sense of his obstruction. If the spirometry confirms the dx, you rx a SABA (e.g. albuterol) for rescue/relief situation and an ICS (e.g. budesonide) for control management (you use current guidelines to assess his severity to determine exact dosages). You discuss w/ Jordan and his mother the importance of avoiding triggers, like Snuggles, as much as possible and you tell them to check back with you in 1-2 weeks to discuss how the new medications are working. You also give Jordan a tutorial on how to take the medications and you develop an asthma action plan to follow if he develops worsening or acute sxs.

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17. Clarence has acute epiglottitis, inflammation of the epiglottis caused by H. influenzae. You do NOT order imaging because this is a respiratory emergency, but if you did, you would see thumbprint sign on xray. You call an ambulance to transport Clarence to the hospital and tell his mother it is important to keep him calm - maintaining an open airway is critical. He will receive IV abx (e.g. ceftriaxone) and a tracheostomy set should be close by. You also consult ID about his unvaccinated household contacts.You also have a discussion with his mom about the importance of vaccinations.

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22. Graham has cystic fibrosis, a condition caused by an abnormal CFTR protein and
    abnormal mucus production. To confirm the diagnosis you may order a quantitative sweat chloride test (> 60 mEq/L is positive) and CFTR molecular testing which identifies the CFTR mutations. Tx will depend on the mutations that Graham has, but he will need pancreatic enzymes when he eats, a high-fat diet, lung function monitoring, and prophylactic abx to prevent infection. Potential therapies include ivacaftor and or lumacaftor, depending on his mutations. Fortunately, new drugs are being researched and release more regularly that are starting to tx the underlying causes of CF.

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28. Colton is a 67 YO male who presents w/ painful breathing that begin this morning. He says it hurts every time he takes a deep breath. He has a 55 pack year hx of smoking, and is retiring next month from Delta where he works as a pilot flying internationally 1x/wk. He takes atorvastatin for hyperlipidemia. Vitals are RR 24, BP 118/78, HR 110, temp 98.6 F, and his BMI is 28. Colton has normal breath sounds and heart sounds but looks uncomfortable and pained. You order an EKG and see S waves in lead I, and Q waves and inverted T waves in lead III and confirm sinus tachycardia. D-dimer comes back elevated. His CXR is normal. What other imaging do you order? How do you dx and tx?

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28. Colton has a pulmonary embolism, a clot that is likely d/t a combination of factors, including his smoking, weight, and frequent sedentary periods during international flights. You admit him, give him supplemental O2, and order a CT angiogram w/ contrast to confirm the dx. You start SQ Lovenox for the interim and discuss w/ Colton that he will need to be on Warfarin from now on as well. You tell him that discontinuing smoking would help prevent future clotting and you encourage him to wear compression stockings and to make sure he avoids long sedentary periods. You tell him you’d like to follow up w/ him in 5 days for another CT to ensure the clot is breaking down.

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34. Doris has bronchial carcinoid tumor, a very rare form of lung cancer. You might better visualize the tumor w/ bronchoscopy. You refer her to oncology for further staging and for evaluation for mets w/ Octreoscan or Ga-68 Dotatate scan. If possible, the tumor will be entirely resected surgically.

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