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Pre-session Number2(Trial-2 /// 8July2013)

Case Review CourseTrial-2 / 17Tir1392

Case: 53-year-old Man

- My breathing requires effort - I feel out of breath - I can't get enough air in

CC: Shortness of breath

(Dyspnea)

Present Illness

- IncreasingShortness of Breath- weight loss

Shortness of breath– Start:• More than a year ago • During vigorous exercise

– Now:• I’m always feeling like this • During routine housework

Shortness of breath– Weight loss over several months

Present Illness

- Non-productive cough - Non-smoker

Cough– All the features:• Dry and hoarse• Non-bleeding

Social history:

Cigarette Smoking– Pack-year?• No history of cigarette

smoking

Occupational Status

I have worked underground in the New York City subway system for the past 20 years.

English Gap!

Patient: “Do I have lung cancer? I’m really afraid of losing my job if this doesn’t get better…is it true?” (He seems really worried)

Job: According to the prognosis: -“Most people with this disease are completely cured” or -“Complete cure may be difficult at this advanced stage, but we have a lot to offer in terms of controlling the symptoms and improving your quality of life.”

Lung cancer:“We don’t know at this point. It could be a (poor) possibility, but we still need to do additional tests.”

Spirometry Test

- FEV1:FVC = 0.7- FEV1 = 60% of expected- The FEV1 improves to 70% of expected with salbutamol treatment.

• A 53-year-old man presents to the clinic with complaints of increasing shortness of breath, a nagging cough, and weight loss over several months. He reports no history of cigarette smoking but has worked underground in the New York City subway system for the past 20 years. Spirometry tests are ordered that demonstrate a forced expiratory volume in 1 second:forced vital capacity ratio (FEV1:FVC) of 0.7, and an FEV1 value that is 60% of expected. The FEV1 improves to 70% of expected with salbutamol treatment.

(A) Asthma (B) Chronic aspiration(C) Emphysema (D) Histoplasmosis(E) Tuberculosis (F) Bronchiectasis

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Answer

A) Asthma

• Answer A is incorrect. Asthma is largely due to hyperreactive airways, which become inflamed and constrict in response to a variety of triggers (cold, infection, exercise, or allergens). The airway constriction, however, is largely reversible with bronchodilator treatment.

B) Chronic aspiration

• Answer B is incorrect. Chronic aspiration typically occurs in one of two settings. First, in the setting of neurologic impairment due to dementia or following a stroke, aspiration may be secondary to a loss of cough and swallow reflexes. Second, a pharyngeal or esophageal disorder, such as laryngopharyngeal or gastroesophageal reflux, cricopharyngeal spasm, strictures, Zenker’s diverticulum, achalasia, or changes post-radiation or post-surgery for neoplastic processes, may also result in aspiration. There is no history that indicates that any of these risk factors are present.

C) Emphysema

• The correct answer is C. This man’s age, symptoms, and history suggest a diagnosis of chronic obstructive pulmonary disease (COPD). The diagnosis is supported by a decreased forced expiratory volume in 1 second:forced vital capacity ratio (FEV1:FVC) of 0.7 and a FEV1 value that is 60% of expected. Although the obstructed airways are not completely reversible, which differentiates it from asthma, it is common to see up to a 15% improvement in FEV1 after bronchodilator therapy, even in patients with COPD. Emphysema is a subgroup of COPD such as chronic bronchitis.

D) Histoplasmosis

• Answer D is incorrect. Chronic histoplasmosis would be associated with a restrictive lung disease pattern, which would result in normal or increased forced expiratory volume in 1 second:forced vital capacity ratio. Also, the subway worker does not directly work with soil, where the histoplasmosis fungus resides. In addition, histoplasmosis is most often found in the midwestern and southeastern states and along the Ohio and Mississippi river valleys.

E) Tuberculosis

• Answer E is incorrect. No history of prior positive purified protein derivative test, immunocompromised status, travel history, or sick contacts are present that would suggest a diagnosis of tuberculosis. Also no history of chills or sweats is given and the spirometry results indicate that a minimally reversible obstructive lung process is at work.

F) Bronchiectasis

• Answer F is incorrect. Bronchiectasis is a disease caused by cycles of infection and inflammation in the bronchi/bronchioles that → permanent fibrosis, remodeling, and dilatation of bronchi. Presents with frequent bouts of yellow or green sputum accompanied by cough, dyspnea, and possible hemoptysis and halitosis. Non of above bolded points were present in this case, besides no history of pulmonary infections (e.g., Pseudomonas, Haemophilus, TB), hypersensitivity (allergic bronchopulmonary aspergillosis), CF, immunodeficiency, aspiration, autoimmune disease (e.g., rheumatoid arthritis, SLE), or IBD is presented.

English Gap!

What is the difference between restrictive and obstructive pulmonary diseases?

Restrictive: Residual value Total Long Capacity

Obstructive: Residual value Total Long Capacity

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Minicases

1

Differential diagnoses Workup

2

Differential diagnoses Workup

3

Differential diagnoses Workup

…

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“Voila l’amour…” victor Hugo

را بی نهایتحسن، بی نهایتبصیرت”در ازل، دید

پدید آمد...“عشقو از این دیدار

”هر کدام از ما )هر ذره از کائنات(، از این نگاه ،هستیمکه

ایم )زیرا وجود، عین زیبایی است( و معشوقاز این نظر که می فهمیم و هوشیاریم و

، عاشق ایم.“بصیر

اوست و معشوق اوعاشق و...

بی نهایت را بی نهایت ، یعنی عشق”خواستن“

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Special Thanks!