Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Caprice Cadacio, MD
PGY-2
May 2, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 54 year-old man with daily wheezing
since age 21.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•
The patient was born in NYC
•
He was in excellent health until his teen years when
he noted some shortness of breath with sports
although he remained active in sports, including
rowing
•
At age 21 he was admitted to an outside hospital
with pneumonia
•
6 months later he had acute shortness of breath
while cleaning his basement and was seen in an
emergency room where he was treated with
terbutaline
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Over the ensuing years, he was treated with albuterol
and theophylline for presumed asthma, and eventually
with nasal steroids, albuterol metered dose inhaler(MDI)
and at times, combined inhaled corticosteroid/long acting
beta agonist inhaler (fluticasone/salmeterol).
• Skin testing for allergies revealed reaction to a variety of
trees, pet dander, dust mites, and ragweed.
• He lost his insurance and had his first Bellevue Hospital
Asthma Clinic visit in 6/2010.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• In the previous month, he had mild daily wheezing, but denied cough,
chest tightness and nocturnal symptoms. He was able to walk an
unlimited number of blocks, albeit slowly. He was using a borrowed
albuterol MDI 2-3x/day
• He denied nasal or sinus congestion, or acid reflux symptoms.
• He denied recent overnight hospitalizations or emergency room visits,
and had never been intubated.
• Respiratory symptoms increased with upper respiratory tract
infections, exposure to animals (cats/dogs), exercise, irritants. His
symptoms were often worse in the spring. As a youth, he had taken an
aspirin and had noted rapid facial swelling.
Additional History
•Past Medical History/Past Surgical History:
•Tonsillectomy in childhood
•Social History:
•Never smoked cigarettes, but parents were smokers, social ETOH,
no illicit drug use
•Self employed stock trader
•No pets, obvious cockroaches, mice infestation
•Family History:
•Daughter has asthma
•Allergies or drug reactions:
•ASA – facial swelling as a young man
•Ragweed, pollen, cats/dogs, dust
•Medications:
•Albuterol MDI as needed
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• Obese, in no acute distress
• Vital Signs: 155/95, 72P, O2 saturation 97% on room air,
Peak Flow 300 L/min
• Physical Exam was notable for absence of respiratory
distress or use of accessory muscles of respiratory. His
chest exam was normal to percussion and auscultation.
He had no rashes.
• The remainder of the exam was unremarkable
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC: within normal limits, without peripheral
eosinophilia
• Basic Metabolic panel: within normal limits
• Hepatic panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Chest X-Ray: flattened diaphragms, clear
lung fields, no pleural effusion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working diagnosis
• Moderate - persistent asthma, uncontrolled
• Received basic asthma education including
avoidance of triggers, asa and NSAID
• Treated with inhaled corticosteroid (Fluticasone
proprionate 220 mcg bid) and albuterol MDI as
needed
• Referred for pulmonary function testing
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Lung function testing
Flow volume curve
Pre
bronchodilator
% predicted
Post
bronchodilator
% predicted
%
change
FVC
43
76
76
FEV1
26
52
97
FEV1/FVC
49
55
TLC
96
RV
184
Predicted
Pre bd
Post bd
Severe airway obstruction with large, but incomplete response to
bronchodilator.
Normal total lung capacity and increased residual volume
consistent with airtrapping
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• He returned to clinic only on 2 additional occasions.
Based on lung function studies, his severity assessment
was increased. At those visits, despite his abnormal lung
function testing and persistent symptoms, he declined to
increase or change his medications.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• His last visit was in April 2012
• He had nasal congestion, daily wheezing and shortness
of breath but not nocturnal symptoms. He was using
albuterol MDI 2-3 times per day
• Peak flow was 270 L/min and chest exam notable for
decreased breath sounds with bilateral mild expiratory
wheezing
• He agreed to use a combined long acting beta agonist
and inhaled corticosteroids and is considering doing
repeat PFT
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Severe-persistent asthma, uncontrolled
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS