Case Study

Case Study 3.1 – Emphysema and COPD

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Chronic Obstructive Lung Disease

Irving, a 65-year-old Caucasian man presented with a complaint of an increasingly persistent cough that produced moderately thick, white mucus. The patient stated that the cough had been present for several years and was particularly severe in the morning on awakening. His wife Ruth was more bothered by the cough than he was and had sent him to the physician so that he might be convinced to stop smoking. On questioning, the patient, who was about 30 lb overweight and had been 40 pack-year smoking history, quit in 2005 and had no other ailments. The physician recommended that he stop smoking, and the patient was lost to follow-up.

Ten years later, the patient (now 75-years-old) reappeared in obvious distress, coughing with wheezing sounds in his chest and complaining of tightness in his chest. The condition had arisen after the patient developed an upper respiratory tract infection. He complained that the wheezing and tight feeling in his chest had occurred on other occasions over the past few years, but that he was currently suffering more than usual. The patient was treated with bronchodilators and antibiotics and responded satisfactorily. Subsequent pulmonary function tests showed some decrease in FEV1.

Over the next several years, the patient’s wife began bringing the patient for his visits. She noted that he had increasing somnolence and some personality changes, and he complained of morning headaches. Laboratory values repeatedly showed that he had elevated red blood cell counts and generally normal white cell counts. Blood gases consistently showed low oxygen and retained CO2. Pulmonary function studies now showed an increase in total lung capacity, a marked decrease in FEV1 since his first evaluation, and a decreased diffusing capacity. The chest x-ray was as depicted in Image 3. The patient was finally admitted to the hospital markedly cyanotic with distended neck veins and an enlarged, tender liver. After a progressively downhill course, the patient died at the age of 83 years.

At autopsy, the lungs looked as shown in the Images. There was also evidence of pulmonary vascular and heart disease, also depicted in the Images.

The following images may help guide your discussion:

• Lung, mucopurulent bronchitis – Gross, cut surface Links to an external site.
• Lung, chronic bronchitis – Low power Links to an external site.
• Lungs, emphysema – Radiograph Links to an external site.
• Lungs, emphysema – Gross Links to an external site.
• Lung, centrilobular emphysema – Gross, cut surface Links to an external site.
• Lung, centrilobular emphysema – Gross, cut surface Links to an external site.
• Lung, emphysema – Low power Links to an external site.
• Lung, emphysema – High power Links to an external site.
• Heart, cor pulmonale – Gross, cut surfaces Links to an external site.
• Pulmonary artery, atherosclerosis – Low power Links to an external site.
• Lung, medial hypertrophy – High power Links to an external site.
• Lung, normal pulmonary vessel – High powerLinks to an external site.
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ALL students will answer Question #1, and Question #11. Then for your INITIAL POST, students with the LAST name starting with the letter:

• A – C: Will answer Questions 2 & 8
• D – F: Will answer Questions 3 & 9
• G – J: Will answer Questions  4 & 10
• K – O: Will answer Questions 5
• P – T: Will answer Questions   6
• U – Z: Will answer Questions  7

Initial posts and responses must be based on various resources such as textbooks, articles, and journals. Medscape, Up-to-Date, Primary Care Pocket Guide, and ePocrates as supplemental resources are acceptable.

1. What is the epidemiology of Emphysema? (CDC; WHO; other sources)
2. What is the definition of chronic bronchitis?
3. What is the definition of asthmatic bronchitis?
4. Did this patient have asthmatic bronchitis?
5. How do these changes differ from the changes seen in a typical case of allergic asthma?
6. How do the changes differ from those seen in bronchiectasis?
7. What x-ray features may be present in cor pulmonale?
8. What is the definition of emphysema? Is this a clinical or an anatomic term?
9. What are the major forms of emphysema? Can they always be distinguished from each other? What are the usual distribution and histopathologic features of each?
10. What lung function tests are useful in distinguishing obstructive vs. restrictive lung diseases?
11. What is the Primary Diagnosis? What are 2 possible differential diagnoses? What is the likely outcome of this case?

 

Case Study 3.2 – Acute Gastroenteritis and Other Related GI Illness

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Manuel Gonzalez, a 39-year-old Caucasian male, had a several-day history of fever and cough, productive of yellow-green sputum, and was brought to the hospital by his partner from their home. He was diagnosed as having pneumonia and was treated with a broad-spectrum antibiotic.

Manuel initially improved, and his temperature became normal. However, 4 to 5 days after beginning treatment, he developed watery diarrhea and was again febrile. A stool sample was obtained with the following results:

• Leukocytes ++
• Ova and parasites – negative for Giardia and E histolytica
• Culture – no Salmonella, Shigella, Campylobacter, Vibrio cholerae, or pathogenic Escherichia coli isolated.
• Enzyme immunoassay ++ for Clostridium difficile toxin

Sigmoidoscopy revealed multiple yellow-white plaques overlying a hyperemic colonic mucosa.

The patient continued on intravenous antibiotics for pneumonia and began a course of oral vancomycin for C. difficile-induced pseudomembranous colitis. His diarrhea resolved, and he was discharged in good health to return home.

Four days post-hospitalization, Manuel returned to your office. He reported a “burning and sharp” abdominal pain in his epigastric area, especially after meals. He decided to see you today because of chest pain upon waking up this morning. 

ALL students will answer Question 1 and Question 8. Then for your INITIAL POST, students with the LAST name starting with the letter:

• A – C: Will answer Questions 2
• D – F: Will answer Questions 3
• G – J: Will answer Questions  4
• K – O: Will answer Questions 5
• P – T: Will answer Questions  6
• U – Z: Will answer Questions 7

Questions for Discussion:

1. What is the epidemiology of acute gastroenteritis in the USA? (CDC; WHO; other sources)
2. Why did our patient develop epigastric pain? Describe the etiology and pathology of pseudomembranous colitis.
3. What causes obstructive sleep apnea in some patients with infectious mononucleosis? How can this disease process (obstructive apnea) affect the GI system?
4. As Manuel’s FNP, will you consider prescribing him metronidazole, why (or why not)?
5. What is the BEST dietary recommendation that you will recommend for this patient? Please detail and explain.
6. Can measles (rubeola) cause GI distress? What type of virus causes measles (rubeola)?
7. Can hematologic diseases cause GI distress? Please give an example and explain.
8. What other differential diagnoses (name at least two) you will consider. Please provide the rationale based on the etiology and pathological sequelae (cellular level).

 

 

NB

Last name begins with “R”