L 9 Pulmonology Clinical Case Studies and

Case Study 1: Chronic Obstructive Pulmonary Disease (COPD) - Mr. Berwanger

• Patient Profile:     - Name: Mr. Berwanger.     - Age/Gender: 67-year-old male.     - Social History (SH): 60 pack-year smoking history; Retired beer vendor.     - Activity Level: Fairly sedentary, though walks with his wife in the evening.     - Habits: 2-3 drinks per day; no illicit drug use.
• Vitals and Anthropometric Data:     - Temperature: $99.3^{\circ}F$.     - Blood Pressure (BP): $138/88\,mmHg$ (Right Arm, Sitting - RAS).     - Pulse (P): $84\,bpm$.     - Respiratory Rate (RR): $18\,bpm$.     - Pulse Oximetry: $94\%$ on Room Air (RA).     - Height/Weight/BMI: $71"$, $235\,lbs$, BMI $32.8$.
• Clinical Presentation:     - Symptoms: Productive cough (mucoid sputum), progressive dyspnea (started years ago, worse with exertion and in the last 6 months).     - Stability: Cough is intermittent but stable.     - Denials: Hemoptysis (blood in sputum), weight loss, fever, swelling, chest pain.     - History: No hospitalizations or antibiotic use in the last year.
• Physical Examination:     - Lung Exam: Prolonged expiration, hyperresonance to percussion, scattered crackles at the bases.     - Negative Findings: No signs of consolidation.
• Worksheet Questions & Discussion:     - Differential Diagnosis: COPD, Lung Cancer, Chronic Bronchitis, Pneumonia.     - Diagnostic Test: Chest X-ray (looking for consolidation; COPD typically shows hyperinflation).
• COPD Clinical Definitions and Diagnosis:     - Characterization: Persistent airflow limitation/obstruction.     - Risk Factors: Smoking, family history (FH) of chronic lung disease, environmental exposures.     - Confirmation: Diagnosis is confirmed by irreversible airflow obstruction, defined as a \text{FEV}_1:\text{FVC \text{ ratio}} < 0.7 that persists on repeat testing in the absence of an alternative diagnosis.     - Imaging: CXR or CT are not strictly required for the primary diagnosis.     - Staging: Multiple indices available, including GOLD ABE, COPD Foundation, and ERS/ATS guidelines.
• General Management for Newly Diagnosed COPD:     - Risk Mitigation: Avoidance of smoking and environmental triggers.     - Immunizations: Pneumococcal, influenza, and COVID-19 vaccinations.     - Activity: Regular physical activity.     - Pharmacotherapy: Short-acting bronchodilators as needed.     - Maintenance: Review of inhaler technique; assessment for hypoxemia/hypercapnia.

Case Study 2: Lung Cancer (NSCLC) - Mr. Mikita

• Patient Profile:     - Name: Mr. Mikita.     - Age/Gender: 67-year-old male.     - SH: Previous smoker (quit 5 years ago), 45 pack-year history; Zamboni driver at a local ice rink.     - Activity/Diet: Occasional bike rides for exercise; normal diet; 2-3 drinks per week; no illicits.
• Vitals and Anthropometric Data:     - Temperature: $97.9^{\circ}F$.     - BP: $108/72\,mmHg$ (RAS).     - Pulse: $78\,bpm$.     - RR: $20\,bpm$.     - Pulse Oximetry: $92\%$ on RA.     - Height/Weight/BMI: $6'1"$, $160\,lbs$, BMI $21.1$.
• Clinical Presentation:     - Symptoms: Intermittent cough, gradual onset of dyspnea (4 months), unintentional weight loss ($15\,lb$).     - Red Flags: Admits to rare blood in sputum (hemoptysis).     - Denials: Abdominal pain, bowel habit changes, chest pain, melena, hematochezia, anxiety, visual changes, sleep disturbances, rash.
• Physical Examination:     - Pulmonary: Dullness to percussion, rhonchi on the right side. Clear to auscultation (CTA) on the left.
• Imaging and Laboratory Findings:     - CBC: Hemoglobin (Hgb) $11.9\,g/dL$, WBC $12,000/mm^3$.     - CXR: Focal lesion in the Right (R) middle lobe with a small pleural effusion.     - CT (Chest/Abdomen with IV contrast): Solitary nodule measuring $2.5\,cm \times 1.5\,cm$ with irregular borders in the R middle lobe. Small fluid collection at the R costophrenic angle.
• Worksheet Questions & Discussion:     - Differential Diagnosis: Lung cancer, Malignancy, Tuberculosis (TB), Congestive Heart Failure (CHF), Atelectasis.     - Definitive Diagnosis Requirements: Biopsy for histopathology.
• Lung Cancer Epidemiology and Management:     - Classification: 85% of cases are Non-Small Cell Lung Cancer (NSCLC).     - Risk Factors: Smoking (90%), radiation exposure, environmental toxins, pulmonary fibrosis, and HIV status.     - Common Symptoms: Cough, hemoptysis, dyspnea, weight loss, and chest pain.     - Diagnosis State: Most cases are diagnosed at an advanced stage.     - Management: Prompt referral to an Oncologist is essential.

Case Study 3: Pleural Effusion - Ms. Liu

• Patient Profile:     - Name: Ms. Liu.     - SH: Nonsmoker; Sporting goods salesperson; Frequent traveler; Adventurous diet.     - Habits: 1-2 glasses of wine daily; no illicits.
• Vitals and Anthropometric Data:     - Temperature: $99.6^{\circ}F$.     - BP: $118/76\,mmHg$ (Left Arm, Sitting - LAS).     - Pulse: $64\,bpm$.     - RR: $16\,bpm$.     - Pulse Oximetry: $97\%$ on RA.     - Height/Weight/BMI: $70"$, $160\,lbs$, BMI $23$.
• Clinical Presentation:     - Symptoms: Non-productive cough; gradually increasing shortness of breath since a trip to Italy 2 weeks ago (hiking and eating raw seafood).     - Denials: Hemoptysis, weight loss, bowel habit changes, abdominal pain, hematochezia.
• Physical Examination:     - Pulmonary: Dullness to percussion at the bases; bibasilar crackles.
• Diagnostics:     - CXR: Small bilateral pleural effusions.     - Thoracentesis/Fluid Analysis: Pleural fluid LDH $125\,U/L$; Serum LDH $165\,U/L$. Fluid showed eosinophilia and visible parasites.
• Worksheet Questions & Discussion:     - Differential Diagnosis: Bronchitis, Upper Respiratory Infection (URI), Pneumonia, Pleural Effusion.     - Transudate vs. Exudate: Exudate based on Light's Criteria regarding High LDH.
• Pleural Effusion Clinical Reference:     - Definition: Abnormal collection of fluid between the visceral and parietal pleura.     - Light's Criteria Rule: Fluid is an exudate if at least the following 1 of 3 criteria is met:         1. Pleural fluid protein/serum protein ratio > 0.5.         2. Pleural fluid LDH/serum LDH ratio > 0.6.         3. Pleural fluid LDH > 2/3 the upper limit of the laboratory's normal serum LDH.     - Common Causes: Infections and malignancy for exudates; Heart Failure (HF) for transudates.

Case Study 4: SARS-CoV-2 (COVID-19) - Mr. Sandberg

• Patient Profile:     - Name: Mr. Sandberg.     - SH: Nonsmoker; Maintenance worker at a hospital; lives in a multi-generational household.     - Habits: 5-6 beers on the weekend; no illicits.
• Vitals and Anthropometric Data:     - Temperature: $101.4^{\circ}F$.     - BP: $142/92\,mmHg$ (RAS).     - Pulse: $88\,bpm$.     - RR: $22\,bpm$.     - Pulse Oximetry: $91\%$ on RA.     - Height/Weight/BMI: $68"$, $208\,lbs$, BMI $31.6$.
• Clinical Presentation:     - Symptoms: 5-day history of dyspnea, fever, occasional cough, body aches, diminished sense of smell (anosmia), decreased appetite, and fatigue.     - Denials: Weight loss, bowel habit changes, headache, visual changes, rash, weakness.
• Physical Examination:     - General: Obese male in mild distress due to dyspnea.     - Pulmonary: Bibasilar crackles; occasional dry cough; negative egophony.     - Cardiac: Regular rate and rhythm (RRR) without murmurs.
• Diagnostics:     - Labs: WBC $11.8 \times 10^3/mm^3$ (slightly elevated); Hgb $13.9\,g/dL$.     - Testing: Influenza A/B rapid assay negative; SARS-CoV-2 RNA by RT-PCR positive.     - CXR: Bilateral ground glass opacities; no consolidation or effusions.
• Worksheet Questions & Discussion:     - Risk Factors for Severe Disease: Obesity, advanced age, interaction with school children/large households, Diabetes Mellitus (DM).     - Management: Outpatient supportive care, infection control, monitoring $O_2$ levels, vaccination. Pharmacotherapy: Nirmatrelvir-ritonavir (Paxlovid).
• COVID-19 Clinical Reference:     - Transmission: Respiratory droplets.     - Incubation: 4-5 days post-exposure (up to 14 days).     - Disease Severity: Mild-moderate disease in 81% of cases.     - Testing: NAAT (RT-PCR) is superior to antigen testing. Samples via nasopharyngeal swab or saliva.

Case Study 5: Community-Acquired Pneumonia (CAP) - Mr. Stolz

• Patient Profile:     - Name: Mr. Stolz.     - SH: Current smoker (23 pack-year); Bartender.     - Habits: 1 beer daily; no illicits.
• Vitals:     - Temperature: $101.7^{\circ}F$.     - BP: $134/84\,mmHg$ (RAS).     - Pulse: $78\,bpm$.     - RR: $22\,bpm$.     - Pulse Oximetry: $95\%$ on RA.     - Height/Weight/BMI: $5'10"$, $175\,lbs$, BMI $25$.
• Clinical Presentation:     - Symptoms: 10-day history of worsening "cold" symptoms; productive cough, chills, chest pain.     - Physical Examination: Rhonchi; positive (+) bronchophony on the left (L). No wheezing.
• Diagnostics:     - Labs: Elevated WBC with left shift; BUN $22\,mg/dL$.     - CXR: Consolidation in the left lower lobe.     - Testing: Influenza and COVID-19 negative.
• Worksheet Questions & Discussion:     - CURB-65 Score: 2 (Points likely for BUN and RR/Age).     - Disposition: Inpatient management recommended for a score of 2+.     - Management Plan:         - Meds: Amoxicillin-Clavulanate, or Monotherapy with a Respiratory Fluoroquinolone (Levofloxacin/Moxifloxacin).         - Lifestyle: Smoking cessation, hydration, follow-up CXR.

Case Study 6: Pulmonary Embolism (PE) - Mr. Payton

• Patient Profile:     - Name: Mr. Payton.     - Activity: Taxidermist; post Right (R) total knee replacement (14 days ago).
• Clinical Presentation:     - Symptoms: Sudden onset of Shortness of Breath (SOB) and pleuritic (inspiratory) chest pain (4/10) 12 hours ago during physical therapy.     - Physical Examination: R knee and calf are swollen and tender; healing incision present.
• Worksheet Questions & Discussion:     - Differential Studies: CT Pulmonary Angiography (CTA), D-dimer.     - Initial Medication: Anticoagulation (LMWH, Apixaban).
• PE Clinical Reference:     - Pathophysiology: Obstruction of a pulmonary artery; 100,000 deaths/yr in the US.     - Site Origins: Proximal lower extremity veins (popliteal, femoral, iliac).     - Diagnosis: High probability requires CT Angiography. Moderate/Low probability uses D-dimer as a screen.     - Treatment: Stabilization, supportive $O_2$, and anticoagulation (LMWH, fondaparinux, rivaroxaban, apixaban, or unfractionated heparin).

Case Study 7: Obstructive Sleep Apnea (OSA) and Pneumothorax - Mr. Cholak

• Patient Profile:     - Name: Mr. Cholak.     - Body Habits: BMI $43.8$ ($76"$, $360\,lbs$).     - Complaints: Chronic fatigue, loud snoring, observed apnea; lower leg swelling.
• Diagnosis Of OSA:     - Diagnostic Standard: Polysomnography (sleep study).     - Management: CPAP, weight loss/bariatric surgery, oral appliances.
• Pneumothorax Reference:     - Primary Spontaneous: Absence of lung disease; typically tall, thin male smokers in their 20s.     - Secondary Spontaneous: Occurs with underlying disease (COPD, Cystic Fibrosis, Malignancy).     - Tension Pneumothorax: Medical emergency; tracheal deviation toward unaffected side, hypotension, distended neck veins.     - Treatment Interventions:         - Needle Decompression: $14-16\text{ gauge}$ catheter at $2nd$ or $3rd$ intercostal space, midclavicular line.         - Tube Thoracostomy: $24-28\,Fr$ ($36\,Fr$ for trauma) at the $5th$ intercostal space, midaxillary line.         - Pleurodesis: Procedure to cause adhesion of pleura via mechanical abrasion or chemical (talc) insufflation.