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Academy Case Presentation. Kevin Pham, PGY-3 July 18 th , 2014. HPI. Chief complaint: shortness of breath 74 yo man was “admitted to the hospital because of pulmonary HTN” and “worsened right sided heart failure.”. HPI. Seven years prior to admission, patient was admitted for a dog bite.

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Academy Case Presentation

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Academy case presentation

Academy Case Presentation

Kevin Pham, PGY-3

July 18th, 2014


Academy case presentation

HPI

  • Chief complaint: shortness of breath

  • 74 yo man was “admitted to the hospital because of pulmonary HTN” and “worsened right sided heart failure.”


Academy case presentation

HPI

  • Seven years prior to admission, patient was admitted for a dog bite.

    • Inspiratory wheezing, digital clubbing, cyanosis, and increased anteriorposterior diameter of thorax on exam.

    • Chest X-ray shows increased marking in bilateral bases and decreases marking in upper fields.

    • Patient was asymptomatic at this time


Academy case presentation

HPI

  • Three years prior to admission, patient was admitted for increased dyspnea.

    • ABG: pH 7.44, PaCO2 14, PaO2 49 on room air

    • PFTs: FVC 73% predicted, FEV1 66% predicted, FEV1/FVC 90%, DLCO 9% predicted

    • Patient did not improve with bronchodilators and was discharged on home oxygen


Academy case presentation

HPI

  • Two years prior to admission, patient was admitted for chest discomfort and dyspnea.

    • Patient was discharge on Lasix, isosorbidedinitrate, and oxygen


Academy case presentation

HPI

  • Fifteen months prior to admission, patient was admitted for dyspnea again.

    • Increase jugular venous pressure, increased anteroposterior thoracic diameter, hyperresonance, diminished breath sound, inspiratory crackles at right lung base, liver 3 cm below right coastal margin, acral cyanosis, digital clubbing, 3+ pitting edema bilateral legs.

    • ABG: pH 7.54, PaCO2 22, PaO2 43


Pulmonary function testing

Pulmonary function testing

60% predicted

73% predicted

105% predicted

175% predicted

117% predicted

13% predicted


Chest x ray

Chest X-ray


Chest x ray1

Chest X-ray

  • Slight cardiac enlargement

  • Hyperexpanded

  • Decreased vascular markings in left upper lobe

  • Fine linear opacities in bilateral bases

  • Small left lung pleural plaque

  • Central pulmonary arteries are dilated


Academy case presentation

HPI

  • Patient was discharged with beclomethasone inhaler, albuterol inhaler, Lasix, nitroglycerin, isosorbidedinitrate, and oxygen


Academy case presentation

HPI

  • Three weeks later, patient stopped using inhalers and was not using oxygen as prescribed.

  • Adherence advised


Academy case presentation

HPI

  • Eight months prior to admission, cardiac echocardiography was done and showed:

    • Right ventricular hypertrophy

    • There was no intracardiac shunt


Academy case presentation

HPI

  • Two months prior to admission, a radionuclide pulmonary scan performed.


V q scan

V/Q scan

  • Multiple areas of decreased perfusion which filled in with equilibrium.

  • Perfusion defects matched with ventilation defects


Academy case presentation

HPI

  • Patient worked in a naval shipyard in welding for 10 years.

  • Patient worked in construction and demolition for 37 years.

  • He also worked in vicinity of sandblasting and fiberglass before.

  • He smoked tobacco 1-2 packs daily for 45 years. He quit 5 years prior to admission.

  • No history of tuberculosis or prior exposure.

  • No family history of pulmonary disease


Review of systems

Review of Systems

  • Chronic productive cough with small amount of sputum

  • Patient denies fever, weight loss, hemoptysis, allergic symptoms, or chest pain.


Physical examination

Physical Examination

  • Vitals: T 36.1 C, P 90, BP 125/90, RR 28 (no pulse ox reported)

  • General: thin, cyanotic in moderate pulmonary distress.

  • HEENT: facial flushing, multiple telangiecstases. JVD 10 cm with hepatojugular reflex

  • Pulmonary: faint breath sound, clear bilaterally, prolonged expiration.

  • Cardiovascular: regular rhythms, pronounced P2, grade 2 holosystolic murmur over left lower left sternal border increased with inspiration.

  • Abdomen: liver palpable 3 cm below right costal margin.

  • Extremities: 3+ pitting edema with increased skin pigmentation and digital clubbing bilaterally.


Laboratory

Laboratory

  • HCT 48.3 CBC otherwise is normal

  • CO2 21, BUN 25, Cr not reported, BMP otherwise is normal

  • Total bilirubin 1.6, direct bilirubin 1.1, LFTs otherwise normal

  • Normal coagulation panel.

  • Normal UA.

  • ABG: 7.34/44/413 on 100% oxygen


Academy case presentation

EKG

  • Pertinent for axis 120 degree, evidence of right atrial enlargement and right ventricular hypertrophy.


Pulmonary arterial line

Pulmonary Arterial Line

  • Right atrial mean pressure 20 mm Hg

  • Right ventricular pressure 100/25 mm Hg

  • Pulmonary arterial pressure 95/50 mm Hg

  • Wedge pressure 10 mm Hg


Hospital course

Hospital Course

  • Hydralazine, captopril, and nitroprusside given with no effects on pulmonary pressure.

  • Nifedipine given with slight improvement in pulmonary pressure.

  • Warfarin started


Pulmonary function testing1

Pulmonary Function Testing


Hospital day 9

Hospital Day 9

  • Worsening dyspnea with diffused wheezing.

  • ABG: 7.50/28/32 on 100% oxygen

  • Intubated.

  • Solumedrol, thephylline, terbutaline, metaproterenol.

  • Chest X-ray with airspace conslidation at right lung base.

  • Ampicillin and gentamicin started.

  • Hemoptysis developed.

  • Heparin drip started in place of Coumadin.

  • Lower extremities ultrasound negative for DVTs.


Hospital day 18

Hospital Day 18

  • Heparin drip stopped.

  • IVC filter placed.

  • Sputum culture positive for Enterobacteraerogenes and Pseudomonas maltiphilia.

  • CXR with partial clearance of airspace consolidation.

  • Weaning failed multiple times.

  • Creatinine and BUN progressively increased.

  • Repeat CXR showed no change.

  • Patient expired on Hospital Day 28


Academy case presentation

Case Discussion


Autopsy

Autopsy


Pathology

Pathology

  • Upper lobes with marked panacinar emphysema

  • Apical segments completed comprised of small bullae

  • Middle lobe, lingula, and lower lobes with interstitial fibrosis. Fibrosis was fine reticulated with no honeycombing.

  • Large number of asbestos bodies present.

  • Pathology consistent with chronic bronchitis.


Reference

Reference

  • Scully, RE, et al. Case 32-1986. New England Journal of Medicine. 315;17:437-449.


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