NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Caprice Cadacio, MD PGY-2 May 2, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint • 54 year-old man with daily wheezing since age 21. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

3. History of Present Illness • The patient was born in NYC • He was in excellent health until his teen years when he noted some shortness of breath with sports although he remained active in sports, including rowing • At age 21 he was admitted to an outside hospital with pneumonia • 6 months later he had acute shortness of breath while cleaning his basement and was seen in an emergency room where he was treated with terbutaline UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

4. History of Present Illness • Over the ensuing years, he was treated with albuterol and theophylline for presumed asthma, and eventually with nasal steroids, albuterol metered dose inhaler(MDI) and at times, combined inhaled corticosteroid/long acting beta agonist inhaler (fluticasone/salmeterol). • Skin testing for allergies revealed reaction to a variety of trees, pet dander, dust mites, and ragweed. • He lost his insurance and had his first Bellevue Hospital Asthma Clinic visit in 6/2010. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

5. History of Present Illness • In the previous month, he had mild daily wheezing, but denied cough, chest tightness and nocturnal symptoms. He was able to walk an unlimited number of blocks, albeit slowly. He was using a borrowed albuterol MDI 2-3x/day • He denied nasal or sinus congestion, or acid reflux symptoms. • He denied recent overnight hospitalizations or emergency room visits, and had never been intubated. • Respiratory symptoms increased with upper respiratory tract infections, exposure to animals (cats/dogs), exercise, irritants. His symptoms were often worse in the spring. As a youth, he had taken an aspirin and had noted rapid facial swelling.

6. Additional History • Past Medical History/Past Surgical History: • Tonsillectomy in childhood • Social History: • Never smoked cigarettes, but parents were smokers, social ETOH, no illicit drug use • Self employed stock trader • No pets, obvious cockroaches, mice infestation • Family History: • Daughter has asthma • Allergies or drug reactions: • ASA – facial swelling as a young man • Ragweed, pollen, cats/dogs, dust • Medications: • Albuterol MDI as needed UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

7. Physical Examination • Obese, in no acute distress • Vital Signs: 155/95, 72P, O2 saturation 97% on room air, Peak Flow 300 L/min • Physical Exam was notable for absence of respiratory distress or use of accessory muscles of respiratory. His chest exam was normal to percussion and auscultation. He had no rashes. • The remainder of the exam was unremarkable UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

8. Laboratory Findings • CBC: within normal limits, without peripheral eosinophilia • Basic Metabolic panel: within normal limits • Hepatic panel: within normal limits UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

9. Other Studies • Chest X-Ray: flattened diaphragms, clear lung fields, no pleural effusion UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

10. Working diagnosis • Moderate- persistent asthma, uncontrolled • Received basic asthma education including avoidance of triggers, asa and NSAID • Treated with inhaled corticosteroid (Fluticasone proprionate 220 mcg bid) and albuterol MDI as needed • Referred for pulmonary function testing UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

11. Lung function testing Flow volume curve Predicted Pre bd Post bd Severe airway obstruction with large, but incomplete response to bronchodilator. Normal total lung capacity and increased residual volume consistent with airtrapping UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

12. Clinical Course • He returned to clinic only on 2 additional occasions. Based on lung function studies, his severity assessment was increased. At those visits, despite his abnormal lung function testing and persistent symptoms, he declined to increase or change his medications. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

13. Clinical Course • His last visit was in April 2012 • He had nasal congestion, daily wheezing and shortness of breath but not nocturnal symptoms. He was using albuterol MDI 2-3 times per day • Peak flow was 270 L/min and chest exam notable for decreased breath sounds with bilateral mild expiratory wheezing • He agreed to use a combined long acting beta agonist and inhaled corticosteroids and is considering doing repeat PFT UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

14. Final Diagnosis • Severe-persistent asthma, uncontrolled UNITED STATES DEPARTMENT OF VETERANS AFFAIRS