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Vascular Disease And Respiratory Failure Case Tutorials

Cases and Notes Compiled by James Allen MD

Case #1
History: 20 yr old Caucasian woman with acute dyspnea, pleuritic chest pain, and hemoptysis PMH: recently started birth control pills SH: OSU student; non-smoker FH: father had phlebitis after hip surgery Exam: HR = 122, RR = 24, BP = 92/60, lungs clear to auscultation

Case #1: ABG

pH PCO2 PO2 HCO3 SaO2 7.50 25 55 21 90%

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Case #1: PFTs

FVC FEV1 FEV1/FVC TLC DLCO 3.27 liters 2.75 liters 92% 4.98 liters 100% 100% 100%

12.3 ml/min/mm 52%

Case #1: Chest X-ray

Case #1: Discussion

What is the differential diagnosis? How would you confirm the diagnosis? What are the likely contributing causes of this disease? How would you treat her? What would you advise her to do regarding future contraception?

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Pulmonary Embolus: Chest CT

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Pulmonary Embolus: Ventilation/Perfusion (V/Q) scan

Ventilation

Perfusion

Pulmonary Embolus: Pulmonary Angiogram

Pulmonary Embolus: Pathology

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Pulmonary Infarction: Pathology

Pulmonary Embolus: Pathology

Pulmonary Embolus

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Older Pulmonary Embolus

Very Old Pulmonary Embolus

Case #2: History

30 year old woman with progressive dyspnea over the past 9 months; she is now unable to carry out household chores and unable to walk 1 flight of stairs Past medical history: normal Social history: married with 2 children Family history: no cardiopulmonary disease

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Case #2: Physical Exam

Vital signs:
225 pounds HR 78 BP 130/79 RR 18

Lungs clear to auscultation 1/VI systolic murmur, loud pulmonic component of the second heart sound, elevated jugular venous pressure Mild pedal edema

Case #2: Chest x-ray

Case #2: Chest x-ray

29 cm 18 cm

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Case #2: PFTs

FVC FEV1 FEV1/FVC TLC Diffusing capacity 2.95 L 2.37 L 80% 4.97 L 16.5 (79%) (75%) (90%) (66%)

6 minute walk: SaO2 98% at rest and 91% while walking

Discussion Questions
What does her physical examination suggest? How do you interpret the chest x-ray? How do you interpret the PFTs? What is the significance of the 6 minute walk results? What additional studies would you order?

Case #2: Cardiac Echo

Normal left ventricle Dilated, hypokinetic right ventricle Dilated pulmonary arteries No evidence of intracardiac shunt

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Case #2: Right Heart Catheterization

Before iNO:
PA = 101/43 Mean PA = 65 PCWP = 7 CO = 4.7 CI = 2.3

After iNO:
PA = 88/42 Mean PA = 56 PCWP = 7 CO = 4.9 CI = 2.6

Discussion Questions:
What is the diagnosis? What is the prognosis? How would you treat her?

Case #3: History

45 year old caucasian man with shortness of breath worsening over the past 3 years. Past medical history: scleroderma Social history: disabled engineer; married with 2 children; non-smoker

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Case #3: Physical Exam

Vital signs:
HR RR BP 104 18 132/72

Lungs clear to auscultation Heart = tachycardic but regular; loud P2; elevated jugular venous pressure; II/VI systolic murmur at right sternal border

Case #3: Chest x-ray

Discussion Questions
What are the pulmonary complications of scleroderma? Which one is most likely in this case? What additional tests could you do to confirm your clinical suspicion? What physical examination findings support this diagnosis? What would a cardiac echo show?

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Case #3: Right Heart Cath

Pulmonary artery pressure = 97/41 (mean = 50) Pulmonary capillary wedge pressure = 8 Cardiac output = 3.6 Cardiac index = 1.8

Case #3: Pathology

Case #3: Pathology

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Discussion Questions
How would you treat him? Why is a pulmonary capillary wedge pressure important to measure when evaluating pulmonary hypertension?

Case #4
51 year old man with new onset seizures and status epilepticus Persistent seizures despite Dilantin, phenobarbital, and Propofol Intubated and started on pentobarbital drip for pentobarbital coma He developed pneumonia after 1 week that improved with antibiotics

Case #4 (continued)
After 2 weeks, he continues to have seizures when the pentobarbital is held. He remains comatose on a ventilator. On rounds, you note that he has developed hypoxemia resulting in an increase in his inhaled oxygen concentration from 30% to 100% On exam, he has new swelling of the right leg

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Case #4 (continued)
What is the most likely diagnosis? What test could you do to prove this diagnosis?

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Image courtesy of GE Healthcare; used with permission

Image courtesy of GE Healthcare; used with permission

Image courtesy of GE Healthcare; used with permission

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Image courtesy of GE Healthcare; used with permission

Case #4 (continued)
What is this patients risk factor(s) for this condition? What could have been done to prevent it? What other tests could have been used in the diagnosis of this condition?

Case #5
History: 44 yr old African American woman admitted with diverticulitis. 6 days after admission, she is febrile and dyspneic PMH: non-insulin dependent diabetes; prior MI SH: non-smoker FH: diabetes Exam (day 6): temp 102, RR = 32, HR = 136, BP = 74/52; severe respiratory distress; lungs clear to auscultation

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Case #5: ABGs (on 100% supplemental oxygen face mask)

pH PCO2 PO2 HCO3 SaO2 7.24 25 52 12 (anion gap = 22) 85%

Case #5: Chest X-rays

Admission

Hospital Day #6

Case #5: Chest CT

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Case #5: Additional Tests

Cardiac echo: LV ejection fraction = 42% Pulmonary artery catheter (Swan-Ganz): pulmonary capillary wedge pressure = 10 mm Hg Blood cultures: E. coli

Case #5: Discussion

What are the possible causes of her pulmonary infiltrates and hypoxemia? How do you know if this is acute respiratory distress syndrome (ARDS) vs. heart failure? How should she be managed immediately?

ARDS pathology

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Case #6: History

19 year old man with increasing confusion and morning headaches Past medical history: Duchennes muscular dystrophy; no surgery, no current medications Social history: disabled after high school Family history: first degree relatives healthy

Case #6: History

Review of systems: wheelchair bound; some difficulty swallowing; requires assistance with activities of daily living

Case #6: Physical Exam

Vital signs:
Afebrile RR = 16 HR = 102 BP = 100/68

Diffuse muscle atrophy Lungs clear to auscultation but both diaphragms elevated to percussion

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Case #6: Chest x-ray

Case #6: PFTs

FVC FEV1 FEV1/FVC TLC Diffusing capacity 1.76 L (52%) 1.48 L (56% 84% 3.54 L (60%) 24 (120%)

Case #6: ABG

pH PO2 PCO2 HCO3 SaO2 7.30 62 68 35 91%

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Discussion Questions
Is this hypercarbic or hypoxemic respiratory failure? What is the cause of his respiratory failure? What is the cause of his confusion? How would you treat him? What is the prognosis?

Case #7: History

60 year old woman with cough and increasing dyspnea for 2 weeks. Her family physician started oral steroids and antibiotics 4 days ago (for presumed exacerbation of COPD) with no benefit yet. For the past 24 hours, she has become much more short of breath Past medical history:
Illnesses: emphysema Surgery: cholecystectomy 10 years ago

Case #7: History

Medications:
Atrovent (inhaled bronchodilator) Serevent (inhaled bronchodilator) Prednisone 40 mg/day (oral steroid) Doxycycline (oral antibiotic)

Social history: 60 pack year smoker - still smokes; real estate agent; divorced

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Case #7: History

Family history: mother died of myocardial infarction; father died of stroke Review of systems: cough productive of yellow sputum; unable to climb one flight of stairs

Case #7: Physical Exam

Vital signs:
Afebrile RR = 32 HR = 112 BP = 134/80

Severe respiratory distress; only able to speak 2-3 words per breath Lungs - barely audible breath sounds; prolonged expiratory phase of respiration

Case #7: Chest x-ray

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Case #7: ABG

Room Air:
pH PO2 PCO2 HCO3 SaO2 7.18 52 74 28 85%

60% oxygen:
pH PO2 PCO2 HCO3 SaO2 7.12 72 80 29 92%

Discussion Questions
Is the main problem acute hypoxemic or hypercarbic respiratory failure? What is the cause of her respiratory failure? How would you treat her respiratory failure?

Case #7: Follow-up

After you successfully manage her in the hospital, her acute illness has resolved and she follows up in your office 2 months later Although her dyspnea has improved, she can only walk one flight of steps and is unable to return to work as a realtor because of limiting dyspnea when showing houses

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Case #7: Outpatient ABG

Room Air:
pH PO2 PCO2 HCO3 SaO2 7.38 52 42 25 87%

SaO2 while walking in the clinic hallway = 78%

Discussion Questions
Is her chronic respiratory failure hypercarbic or hypoxemic? How would you treat her?

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