MedicoPlexus
Clinical Cases in Pulmonology
Gitty George
Name: Patient 1 (female) [PULMONOLOGY]
Age: 63yrs (Upon initial inspection: looks generally her age; healthy for her age)
Occupation: Runs private business
Chief complaint: severe dyspnea
A brief background to the chief complaint: She was having severe dyspnoea approx. 1 week ago. The patient initially went to her GP, who did an x-ray. Pneumonia was determined by this x-ray. She was prescribed a 5-day antibiotics course. There was no specific improvement and a 2nd x-ray was performed, which now showed pleural effusion. The development of dyspnoea led to the referral to St Marina’s Hospital. Now on stronger antibiotics, with significant improvement reported by the patient.
• Site: Where exactly? N/A
• Onset: When did it start, was it constant/intermittent, gradual/ sudden? 1 week ago
• Character: What is the pain like e.g. sharp, burning, tight? No chest pain, but feels some tightness and pressure in the chest.
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain, e.g. sweating, vomiting. No other specific complaints reported.
• Time course: Does it follow any time pattern, how long did it last?
• Exacerbating / relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain, consider using the 1-10 scale?
Other questions/symptoms asked: no high temp/fever, no cough, no specific sleeping problems, no dyspnoea when sleeping, no heart palpitations, no dizziness, no headaches,
Even when she feels perfectly healthy, she can’t take more than 20 stairs without having to stop and catch her breath – severe dyspnoea. Patient started experiencing lung problems from the age of 40yrs and has continued since then. She doesn’t remember having any respiratory issues during childhood.
Past Medical History:
Previous infections: Patient develops bronchitis every year during winter
Previous surgeries: Angioplasty and stent placement in 2014 after severe atherosclerosis. (NOTE: stent is placed when at least 90% of the artery is blocked)
Any congenital conditions:
Drug History:
What is being taken: Current antibiotics; Antihypertensive therapy medication for high BP
Dosage and how often: –
Any allergies: No
Family History:
Hypertension: Her mother had high BP and died due to myocardial infarction
Diabetes/Cholesterol/Genetic Conditions: No
Social History: Smoking: Patient has been smoking for the past 30 years and continues to do so; 10-20 cigarettes per day.
Alcohol: No
Illegal substance usage: –
Drives or not: –
Review of Systems:
Cardiovascular: Has high BP/hypertension
Gastrointestinal: Neurology: Genitourinary/Renal: Musculoskeletal:
Auscultation: Crackles on expiration on the lower border of left lung.. like paper fluttering
Expression of breathing is lower, much more muted on the right side… this is the area of pneumonia.
Blood test results: Increased leukocytes, C reactive protein (CRP) – a marker for inflammation
Right side pleural effusion with characteristics of pneumonia
Signs of inflammation according to imaging done suggesting pneumonia
Sputum has bacteria but not specified
An x-ray and CT scan will be done to check progress and follow-up
Point to remember from the seminar: In the case of lung oedema of the whole lung…. boiling water sound … in severe cases, you can hear without a stethoscope. .. broadly categorised as coarse crackles.
Name: Patient 2 (male) [PULMONOLOGY]
Age: 79
Occupation: Truck driver for the transport of pesticides/chemicals in similar nature
Chief complaint: Dyspnoea and Persistent cough
History of chief complaint: He came to the hospital due to his lung problems. This is his first hospital admission here in Varna (at St Marina’s). He has had previous admissions at other cities.
Site: Where exactly is the pain? No chest pain reported.
Onset: When did it start, was it constant/intermittent, gradual/ sudden? Has had a cough for the past 20-25 years.
Character: What is the cough like? It is present all the time, morning, afternoon, evening etc. He wakes up during the night due to the cough, so had sleeping problems,
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with it, e.g. sweating, vomiting? He has sputum, so he has a productive cough, but hard to expel. The colour of the sputum is sometimes yellow, sometimes white, at the moment it is white/clear. Rarely coughs up blood.
Time course: Does it follow any time pattern, how long did it last?
Exacerbating/relieving factors: Does anything make it better or worse? He tends to cough when he can’t breathe. His throat also gets dry making it worse. It is easier for him to breathe when he is lying down.
Severity: How severe is the pain, consider using the 1-10 scale?
Other questions: No problems eating/swallowing, he doesn’t have to talk much so not much difficulty speaking. No report of fever.
Past Medical History:
Previous infections: No infections in recent times, so within the last 2 weeks.
Previous surgeries: No Any congenital conditions: N/A
Drug History:
What is being taken: He has medications – details not taken from the patient.
Dosage and how often:
Any allergies: /
Family History: His father died from colon cancer.
Hypertension: Diabetes: Cholesterol: Genetic Conditions:
Social History:
Smoking: Used to smoke 1 or 2 packs per day, but stopped 30 years ago.
Alcohol: Stopped at the same time as he stopped smoking.
Illegal substance usage: Drives or not:
Review of Systems:
Cardiovascular: Respiratory: Gastrointestinal: Neurology: Genitourinary/Renal: Musculoskeletal:
Auscultation: Wheezing present in expiration. Present in both lungs, but there is a stronger expression on the left side.
Review of his official documents: COPD has been diagnosed.
Results from his CT scan shows:
- Mediastinal cancer
- Obstruction of his left upper bronchus, tumour formation of 3cm
- Liver lesions, most probably cysts and not metastasis from cancer.
Lung collapsed, emphysema
NOTE: It is important to do the spirometry test to diagnose COPD.
Find below his blood test results: they are well-presented for his condition and case.
(pH normal, pCO2 high, pO2 normal, HCO3 high, BE high, Hb normal, Hct normal, s02 normal, Na+/K+/Cl- all normal, AnGap borderline)
Name: Patient 3 (male) [PULMONOLOGY]
Age: 67
Occupation: Retired for last 20yrs, but he used to work as a common worker/mechanic on a ship
Chief complaint: Dyspnoea
History of chief complaint: He was admitted 3 days ago at St Marina’s Hospital due to difficulty breathing. He gets tired easily and reports having pneumothorax.
Site: Where exactly is the pain?
Onset: When did it start, was it constant/intermittent, gradual/ sudden? Dyspnoea continuously present
Character: What is the dyspnoea like? He can’t walk a lot at all due to dyspnoea. Always sitting up
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with it, e.g. sweating, vomiting? No coughing, no chest pains
Time course: Does it follow any time pattern, how long did it last?
Exacerbating/relieving factors: Does anything make it better or worse? Sleeping upright with pillows to prop-up help, because he can’t breathe when lying flat.
Severity: How severe is the pain, consider using the 1-10 scale?
Past Medical History: He has been admitted previously many times. Reports no childhood lung infections.
Previous infections: in 2003, he had pleural effusion. It was drained 2 times [treat the following statement with doubt! “Patient reports that during the 3rd drainage, due to the doctor’s mistake, he got pneumothorax and that’s when his lung problems started. He had surgery for the pneumothorax the same day it happened and only woke up 8 days later from coma”]
Previous surgeries: /
Any congenital conditions: /
Drug History:
What is being taken: Many!
Dosage and how often: /
Any allergies: /
Family History: His father, mother, brother and sister – all have lung problems. His mother died at 38yrs of age due to a lung problem which he doesn’t know exactly.
Hypertension: /
Diabetes: No
Cholesterol: / Genetic Conditions: /
Social History:
Smoking & Alcohol: The patient hasn’t smoked or drank alcohol for the last 18 years.
Illegal substance usage:/ Drives or not: /
Review of Systems:
Cardiovascular: Patient reports having some heart problems – some kind of heart failure, but not advanced – taking medication for it.
Gastrointestinal: His stomach seems to be getting larger. Endoscopy was done and nothing was found. He takes herbal treatment for it – lemon, bicarbonate etc. No stomach ulcers, generally good stomach. No problems with bowel movement. Apparently, has scurvy but not due to vitamin C?
Neurology: / Genitourinary/Renal: / Musculoskeletal: /
Percussion: dull on right lung
According to the patient’s hospital records:
He has had COPD for 16yrs (emphysema type)
He has a productive cough with yellow sputum
He has arterial hypertension and due to the prolonged period of this condition, his heart is failing – chronic left-side heart failure.
His liver is reduced in size.
He has Bechterew disease (Ankylosing spondylitis) – a rare type of arthritis that causes pain and stiffness in your spine. The hardness of the spine and ligaments.
He has repeated hospital admissions – he comes to the hospital, gets better, goes home and gets worse and comes back.
Note: he can get pneumothorax from his COPD, so most probably isn’t the doctor’s mistake as stated by the patient above. Other details such as ‘no coughing’ are contradicted in the hospital records, so REMEMBER: Don’t always believe the word for word of what the patient tells you.
Name: Patient 4 (male) [PULMONOLOGY]
Age:79
Occupation: Builder/construction environment
Chief complaint: Dyspnoea and cough with sputum produced
History of chief complaint: The patient was rushed to St Marina’s Hospital via ambulance ER on Saturday 24th October 2020 due to complaints of severe dyspnoea.
Site: Where exactly? He can feel some vibrations and pressure in his chest.
Onset: When did it start, was it constant/intermittent, gradual/ sudden? The cough started 10 days ago but gradually increased.
Character: What is the cough like? Cough has sputum production. Sputum is anything from bright pink to dark brown. Cough appears mainly during the night but is also present during the day. Sputum production is mainly at night, with ‘bloodish’ things in his phlegm/sputum.
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with it, e.g. sweating, vomiting? Time course: Does it follow any time pattern, how long did it last? Dyspnoea is present all the time.
Exacerbating/relieving factors: Does anything make it better or worse? When he lies down, his cough and dyspnoea are worse/increases. At home, he sleeps with 2 or 3 pillows propped up.
Severity: How severe is the pain, consider using the 1-10 scale?
Past Medical History: This hasn’t happened before.
He has had some gallbladder stones before.
Previous infections:
Previous surgeries:
Any congenital conditions:
Drug History:
What is being taken: beta-blocker, some prostate medicine, some diuretics.
Dosage and how often: /
Any allergies: /
Family History: No
Hypertension: No
Diabetes: No
Cholesterol: Genetic Conditions:
Social History:
Smoking: He used to smoke when he was 19/20yrs old but not for long, and since then not smoked.
Alcohol: 50ml every day like wine etc.
Illegal substance usage: / Drives or not: /
Review of Systems:
Cardiovascular: He has heart palpitations, which is why he takes the beta-blocker, to help synchronise his heartbeats.
Gastrointestinal: / Neurology: / Genitourinary/Renal: / Musculoskeletal: /
Physical examination and vital signs:
Made the patient lie down flat on his bed, to check his diaphragm movement for the number of breaths per minute. The physical count wasn’t taken, but visibly could be seen that he had an increased number of breaths.
BP 1: 140-120/32
BP 2: 130/40
According to patient’s records:
Diagnosis: Pneumonia (determined from the x-ray and the sputum culture – bacteria was found to have grown in the petri dish from the culture taken)
Name: Patient 5 (female) [PULMONOLOGY]
Age: 64yrs
Occupation: Doctor (still working) on the paediatric ambulance. She has previously worked for 13 years in Libya for 3 periods. In 2007 came back from Libya.
Chief complaint: Cough and difficulty breathing
History of chief complaint: Patient came to the hospital due to cough and difficulty breathing. She had gone to her GP previously and had an x-ray done. She was treated with antibiotics orally. No sign of improvement. The 2nd x-ray was done and was referred to hospital. Patient came to the hospital by herself in a taxi with the x-ray scan and she was admitted at 3 pm on 26/10/2020.
Site: Where exactly?
Onset: When did it start, was it constant/intermittent, gradual/ sudden? Has had the cough for 10 days.
Character: What is the cough like? Clear sputum produced in the morning. Cough is worse/severe at night.
Radiation: Does it radiate/move anywhere? The pressure is felt in the chest.
Associations: Is there anything else associated with it, e.g. sweating, vomiting? No other pains, no daily cough?
Time course: Does it follow any time pattern, how long did it last?
Exacerbating/relieving factors: Does anything make it better or worse? She has to sleep propped up at a 45-degree angle and not flat.
Severity: How severe is the pain, consider using the 1-10 scale?
Past Medical History: 6 years ago she was diagnosed with lung cancer. She underwent treatment for it – 6 rounds of chemotherapy and cancer resolved. The tumour was mediastinal, and touching the right bronchi.
Previous infections: /
Previous surgeries: No
Any congenital conditions: /
Drug History: antihypertensive therapy (not severe so occasionally)
What is being taken:
Dosage and how often:
Any allergies: No
Family History: None
Hypertension: No bp
Diabetes: No
Cholesterol:
Genetic Conditions:
Social History:
Smoking: Smoked since 50years – 1 or 2 packs daily.
Alcohol: No
Illegal substance usage:/ Drives or not:/
Vital signs:
Respiratory count: 23-24/1min (normal: 12-20/1min) so this is a bit high for the patient = tachypnea
BP: 110/60
Auscultation: small fine crackles on right side, generally duller sound than expected. The left seems normal/can be heard clearly.
Prognosis: Pneumonia from the sputum, but waiting for x-ray results to officially diagnose.
Name: Patient 6 (male) [PULMONOLOGY]
Age:
Occupation: Selling clothes
Reason for hospital admission: On 23/10/2020, whilst he was driving his car, he experienced some chest tightness, chest pain and light-headedness. The patient thought he was having a myocardial infarction (MI). He was rushed to the hospital via an ambulance and admitted. This is the second time such an episode has occurred. He had a MI on 27th April 2020.
He has bronchial asthma; occasionally experiences dyspnoea.
Site: Where exactly is the pain? When he coughs, he has pain on the top right side of his upper stomach/lower chest area.
Onset: When did it start, was it constant/intermittent, gradual/ sudden?
Character: What is the cough like? Only when he has asthma attacks, he has a cough and produces clear sputum with the cough.
Radiation: Does it radiate/move anywhere?
Associations: Is there anything else associated with it, e.g. sweating, vomiting?
Time course: Does it follow any time pattern, how long did it last?
Exacerbating/relieving factors: Does anything make it better or worse?
Severity: How severe is the pain, consider using the 1-10 scale?
Past Medical History: He has liver steatosis too.
Previous infections:
Previous surgeries: Angioplasty for stent placement, surgery for hernia too (noted the scar on his stomach on inspection)
Any congenital conditions:
Drug History:
What is being taken: He takes medication for duodenal ulcer, blood thinners because he has a stent inserted in his arteries.
Dosage and how often:
Any allergies:
Family History: His mother has high BP and diabetes.
Hypertension: Has BP
Diabetes: Has Type 2 diabetes
Cholesterol: No
Genetic Conditions:
Social History:
Smoking: Patient has been smoking for 20 years – 2 or 3 cigarettes a day
Alcohol: /
He has a bloated stomach on inspection.
Vital signs:
Bp: 110/70
Auscultation: Crackles heard on the lower left side more prominently. The right side is not so intense.
According to diagnosis: Patient has atherosclerosis; when 80-90% block of the arteries occur then heart ischaemia takes place and this mainly appears in the coronary arteries. MI
In this patient’s case, ischaemia appears on low activity because he has lipidemia due to low fat metabolism as a result of his diabetes. This factor alone means that the fact he has a stent insertion and a previous MI is not relevant, because all his arteries are susceptible to blockage as well.
Name: Patient 7 (male) [PULMONOLOGY]
Age: 61
Occupation: For 3 years he worked in a concrete factory, and then he was constructing houses.
Why did he come to the hospital? He had high cholesterol. He took the medication to lower it for 7 days. His whole body swelled-up = anasarca. He stopped taking the medication and all oedema cleared out. He went to see his GP due to the allergic reaction he had with the medication. His GP did a basic chest x-ray. It was not explained to him and he was referred straight to St Marina’s Hospital.
Chief complaint: Cough, pain and dyspnoea
History of chief complaint: /
Site: Where exactly is the pain? Over his belly area and lower chest area.
Onset: When did it start, was it constant/intermittent, gradual/ sudden? The cough has been present for 3 weeks. The pain was very severe during the night last week. It has never happened before according to the patient.
Character: What is the cough like? No sputum produced. Patient experiences chest tightness on the lower left chest area.
Radiation: Does it radiate/move anywhere? Stomach pain has been present for the past 2-3 weeks. It’s a dull pain – doesn’t particularly increase or decrease much.
Associations: Is there anything else associated with it, e.g. sweating, vomiting? He has dyspnoea with minimal activity, so just 15-20 steps.
Time course: Does it follow any time pattern, how long did it last?
Exacerbating/relieving factors: Does anything make it better or worse? Dyspnoea doesn’t increase when lying flat.
Severity: How severe is the pain, consider using the 1-10 scale?
Other: Patient has nail clubbing – he reports that his nails used to be much flatter. He has also lost 9kg in the last 2 weeks.
Past Medical History: doesn’t report any other conditions
Previous infections:/ Previous surgeries:/ Any congenital conditions: /
Drug History:/ What is being taken:/ Dosage and how often:/
Any allergies:/
Family History: Nothing particular according to the patient.
Hypertension:/ Diabetes:/ Cholesterol:/ Genetic Conditions:/
Social History:
Smoking: He has been smoking since 11yrs of age!
Alcohol: 2litres of beer every day
Illegal substance usage:
Drives or not:
Vital signs:
No changes in consciousness so he is AWAKE.
Respiratory count/rate: 6 for 15seconds so 24/min. Slightly high (normal = 12-20/min)
Bp: 110/40
Pulse: increased
Inflammation of veins, deep vein thrombosis.
Blood test: increased neutrophil levels, increased CRP (a marker for inflammation)
Waiting for a chest x-ray
FOLLOW UP!!! (cancer suspicion)
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