I HUMAN CASE WEEK #4 60 YEAR OLD FEMALE REASON FOR ENCOUNTER: SHORTNESS OF BREATH CASE, Exams of Health sciences

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COMPREHENSIVE I HUMAN CASE WEEK

#3 60 YEAR OLD FEMALE REASON FOR

ENCOUNTER: SHORTNESS OF BREATH I

HUMAN CASE STUDY LATEST UPDATE

Diagnostic tests:

**1. CXR PA and lateral $114-$

2. CBC: $14-$
3. PFT’s $379-$
4. 12 lead ECG $118-$
5. ABG $
6. BNP $59-$
7. D-dimer $17-$
8. Ct chest $350-$
9. Echocardiogram, transthoracic $1,200-$2,
10. Alpha 1 antitrypsin $
11. CTA (not recommended at this time) $
12. Troponin I $18-$
13. Pulmonary ventilation/perfusion scan $487-$
14. Stress echocardiogram $
15. Cardiac stress test $**
    1. CXR PA and lateral
    2. CBC
    3. PFT’s
    4. 12 lead ECG
    5. ABG
    6. BNP
    7. D-dimer
    8. Ct chest
    9. Echocardiogram, transthoracic
    10. Alpha 1 antitrypsin
    11. CTA (not recommended at this time)
    12. Troponin T
    13. Pulmonary ventilation/perfusion scan
    14. PPD( statesIt is in not needed at this time )
    15. Stress echocardiogram
    16. Cardiac stress test
    17. Troponin I
    18. Acetylcholine receptor antigen

More? I did these tests below and got 89% - i didn’t get any that said they were not necessary — idk if maybe they don’t give that feedback anymore? 12 - Lead ECG · Normal rhythm and axis · Mild LVH · No ischemic changes Alpha 1 antitrypsin, blood · Normal · 1.6 (1.5-3.5) ABGs · Arterial pH 7.40 (7.35-7.45) · PaCO2 42 (35-48) · Pao2 53 (83-108) LOW · Bicarbonate 26 (22-26) · Carbon dioxide 23 (17-20) · Oxygen saturation 87% (95-99) LOW · Base Excess - 2.4 (-2.4-+2.3) Brain natriuretic peptide · 3. · Barely above the upper limit of normal Cardiac stress test · Normal Chest CT

· Severe upper lobe and mid lung zone centrilobular emphysema, sparing the lung bases · No interstitial infiltrates or pleural plaques d- Dimer, blood · 44 (0-

300. · Normal Echocardiogram, TTE · LVH · e/e ratio suggests mildly impaired diastolic relaxation · mild left atrial enlargement · mild aortic stenosis · mildly elevated pulmonary artery systolic pressure at rest (35mmHg) but normal RV size and function Pulmonary Function Test · FEV1 = 1.1 liters (30% predicted) · FVC – 2.5 liters (50% predicted) · FEV1/FVC = .44 (61% predicted) · Diffusing capacity of the lungs for carbon monoxide (corrected for Hgb) = 8. ml/min/mmHgb (40% predicted) · After albuterol FEV1 increases to 1.25 liters (an increase of 14%) and FVC increases to 3.0 liters (an increase of 20%) with FEV1/FVC decreasing to .44 (58% predicted) · Lung volumes prior to albuterol show total lung capacity TLC = 5. liters (92% predicted) · Residual volume = 3 liters (200% predicted) · Functional residual capacity = 3.5 liters (100% predicted) · Exertional oximetry shows SaO2 dropping to 86% on room air with walking 200 feet with patient complaining of moderate dyspnea

Stress echocardiogram · Normal Troponin I · Normal Troponin T · Normal Ventilation/perfusion scan · Normal Chest PA/Lateral · Normal lung volumes · Decreased lung markings in upper lobes · Diaphragms flat · No interstitial or alveolar infiltrates · Heart size upper limits of normal · No effusions · No nodules or masses · No obvious adenopathy . Possible management plan: Final DX: COPD Admit to the hospital Meds: In-office: Duoneb (ipratropium bromide/albuterol nebulizer) 0.5mg/2.5mg per 3mL inhaled q min x3 if needed

Rx: Albuterol HFA (90mcg/at) Sig: 1-2 puffs q4 hours prn for SOB/wheezing Disp: 1 inhaler Refill: 2 Rx: Umeclidinium-vilanterol 62.5mcg/25mcg per inhalation Sig: 1 inhalation QD Disp: 1 inhaler Refill: Rx: Prednisone 40mg tablet Sig: 1 tablet QD x 5 days with food Disp: 5 tablets Refill: 0 Rx: Amoxicillin-clavulanate 875mg tablet Sig4: take 1 tablet PO BID x5 days Disp: 10 tablets Refill: 0 Referrals: Pulmonology and pulmonary rehab, allergist, cardiology, nutritionist (?) Education: Encourage weight loss, diet/exercise, proper use and routine cleaning of CPAP machine to avoid PNA. Assess inhaler technique for initiation and every visit after. home oxygen needed Encourage medication compliance. Encourage a diet high in protein, high fiber, cut back on carbohydrates, monitor blood sugars and check weight same time daily, keep log for provider evaluation. Seek emergency care if patient develops severe chest pain and/or SOB that is unrelieved with rescue medications. Keep log of BPs for one week for reassessment of BP medication control (take BP morning and evening).

Follow-up: Follow up in 48 hours for reevaluation. Exercises: 88% 1 c 2 d 3 a 4 d 5 acd 6 bd 7d 8 ac Good Questions:

1. How can i help you today ● I'm having trouble breathing. My wife made me come in. She’s worried about me.
2. Do you have any other symptoms or concerns we should discuss ● An allergic cough and runny nose. I get the cough every year during this season.
3. Do you wheeze? ● Normally just when my allergies act up. Lately ive sort of noticed wheezing at night. Thats fairly new I guess.
4. Are you short of breath when lying down? ● I'm always SOB
5. Do you sleep with pillows to help you breathe? ● Just 1 pillows
6. Does anything make your cough better or worse? ● My coughing is worse when the trees shed pollen
7. Are you taking any prescription medications? ● Yes indeed. I brought my list with me here. Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though it’s not really a medicine.
8. Are you taking any OTC or herbal medications?

● Aleve for shoulder pain and Allergra for the allergies

9. Do you have any allergies? ● Sulfa drugs, I am pretty sure im allergic to tree and grass pollen and ragweed
10. Do you now or have you ever smoked or chewed tobacco ● I was a big time smoker in the past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do.
11. Do you have a problem with fatigue/tiredness ● I sure do. I get tired when i exert. I think im really out of shape, but i also don't sleep great due to sleep apnea, and this makes me tired during the day too
12. Have you been having fevers? ● no
13. Is there any swelling in your ankles? ● Sometimes. Not bad though
14. Do you have a problem with generalized weakness? ● Weakness? No, I dont think i’d call it that really
15. Do you have a cough? ● Not normally, but i have been coughing for the last couple of months
16. Are you coughing up any sputum? ● Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting.
17. When did your difficulty breathing start? ● About 10 years ago. Past 5 years its affected me more and more
18. Does anything make your difficulty breathing better or worse? ● Sitting still is the best for my breathing. Also it helps if i purse my lips when i breathe out
19. Do you become short of breath with exertion? ● Yes definitely. I can walk slowly to the postbox or from room to room ok, but I'm out of breath going upstairs to the bedroom or just lifting stuff
20. Are you short of breath at rest? ● Yess just these past couple months
21. Do you have any pain or other symptoms associated with your difficulty breathing? ● Symptoms? Like cough with runny nose. What else do you mean?
22. Has there been any change in your difficulty breathing over time?

● Big time! I used to be able to walk, work, and run with the best of them. But not now

23. Do you have unusual heartbeats / palpitations? ● No.
24. Do you have any pain in your chest? ● No.
25. Can you tell me about any current or past medical problems? ● High blood pressure, sleep apnea, and type 2 DM. Ive had the blood pressure thing for maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I guess thats all i can think of thats important.
26. Any recent acute or chronic infections? ● No.
27. Any previous medical, surgical, or dental procedures? ● I had my gall bladder removed 20 years ago. I had an accident 30 years back and i had a surgery to fix my shoulder and for the wound in my leg. I guess that's the big stuff
28. Have you ever been hospitalized? ● Just when i had to have some surgery
29. Do you have a family history of heart disease? ● My father died of a heart attack when he was 52. He had HTN and DM and was a smoker. My brother had HTN and heart disease too but passed from cancer
30. Do you drink alcohol? ● A beer with my supper sometimes a couple more when im watching a game
31. Tell me about your work ● Construction… master carpenter, then rose to foreman. I retired at 59. Too tough to continue 32. Does your chest feel tight or heavy? ● No.
32. How severe is your difficulty breathing? ● It seems pretty bad to me. I mean, its affecting my life too much
33. Does anyone in your family have difficulty breathing? ● Not that I've noticed
34. Are you coughing up blood? ● No thank God
35. Do you have a history of lung disease?

● Never evaluated for it, though probably should be. I was exposed to asbestos years ago - and we now know thats bad stuff. Of course there were the usual fumes from stuff around you on the job site, like welding and stuff like that

37. Do you now or have you ever had cancer? ● No thank God
38. Have you had TB? ● Not that i ● I've been told 39. Do you have asthma? ● Not been diagnosed but I'm starting to think maybe that's what's wrong with me now.
39. Do you have a family history of blood clots in your legs or lungs? ● no
40. Do you have a history of deep vein thrombosis or pulmonary embolism? ● I do have ugly varicose veins. Is that the same thing?
41. Do you have heart disease and/or have you ever had a heart attack? ● Never had a heart attack, but sometimes i worry about it a bit
42. Is there any swelling in your legs? ● Haven't noticed that at all
43. Have you ever been diagnosed with thyroid problems? ● no
44. Do you awaken at night short of breath? ● Not so far
45. Do you recently travelDo ● no
46. Is there any swelling in your feet? ● Yeah, and my shoes dont fit
47. Have you ever been told that you have a heart murmur or valve problem? ● Yes a murmur. Ive had it all my life but they said not to worry about it
48. Do you have a history of heart failure? ● No one has ever told me that. Is that different than a heart attack

50. Do you have high cholesterol?

● I dont think so. No one has ever told me that one

51. Do you have chills?

● no

52. Do you have a history of cystic fibrosis?

● no

53. Do you have a history of valvular heart disease?

● no

54. Have you been diagnosed with a bleeding disorder?

● No

55. Have you had chicken pox, measles mumps or rheumatic fever? ●

Not that I recall

56. Are you eating alot of salty food? Not really

57. Do you have muscle pain or cramping?

● No

58. Do you have a sensation of a pounding heart in your chest?

● No

59. Do you have difficulty chewing?

● no

60. Do you have a problem with movement?

● nope

61. Did you ever have involuntary strange dance like movements?

● No i have not

62. Did you have strep throat as a child?

● Not that I remember 63. Have you recently had surgery?

● no

64. Have you eaten anything out of the ordinary lately?

● No nothing out of the ordinary

65. Do you have arthritis?

● no

66. Do you feel faint or like you might faint?

● Nope, never have passed out

67. Have you noticed any trouble with your speech?

● nope

68. Do you have a problem swallowing?

● nope

Physical exam:

1. Auscultate lungs- expiratory wheeze bilaterally, possible crackles heard but only able to choose one answer
2. Inspect mouth and pharynx

3. Look up nostrils
4. Visual inspection anterior/posterior chest ( did palpate and percuss also)
5. Auscultation heart sounds- mitral valve regurgitation 6. Visual inspection of extremities 7. Palpate extremities 8. Capillary refill? 9. BP - 144/92, normal pulse pressure, hypertensive ( the video at the end has his vitals as follows : BP- 145/90 RR HR 96 sa02 95%) Ed 10. Eyelid ice pack test
6. Inspect-????
7. Fundoscopic exam KEY FINDINGS:
8. Dyspnea MSAP
9. Cough
10. BLE Edema +
11. Bilateral Expiratory Wheezing
12. White sputum production
13. Cobblestoning oropharynx
14. Asbestos exposure
15. Smoking history 40 years one pack a day
16. Sleep apnea
17. Fatigue
18. Elevated BP
19. Use of accessory muscles
20. Hx of HTN and DM controlled Lead diagnosis: COPD Differential Diagnoses:
21. Emphysema
22. Chronic Bronchitis
23. Anemia
24. Pneumonia - community acquired
25. Heart failure
26. Asbestosis
27. Lung cancer

8. Mitral regurgitation?( I would not put that one, I can not find any resources that states it as a differential) 9. Bronchiectasis? ( I agree) 10. Pulmonary embolism? 11. Asthma? ( i agree) 12. Tuberculosis 13. Pulmonary HTN (I got 80% by taking out MG, Pneumo Asbestosis, lung cancer, and TB, i think they were ruled out w/ testing) Must Not Miss
9. Emphysema
10. Lung cancer u 3.Heart failure More?
11. Tuberculosis
12. Pulmonary Embolism
13. Myasthenia gravis
14. Lou Gehrig disease? I put the ones below and got 67 %

ALT diagnosis Asthma? Bronchiectasis? More?

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