NYU Medical Grand Rounds Clinical Vignette

Caprice Cadacio, MDPGY-2

May 2, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 54 year-old man with daily wheezing since age 21.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•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.

History of Present Illness

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

• 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

Working diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Lung function testing

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Pre bronchodilator

% predicted

Post bronchodilator

% predicted

% change

FVC 43 76 76

FEV1 26 52 97

FEV1/FVC 49 55

TLC 96

RV 184

Flow volume curve

Severe airway obstruction with large, but incomplete response to bronchodilator. Normal total lung capacity and increased residual volume consistent with airtrapping

Predicted

Pre bd Post bd

• 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.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Severe-persistent asthma, uncontrolled

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS