PULMONOLOGY FILES

PULMO_2

NOTE

Has had recurrence of the catching feeling when he tries to breathe, usually at night.  Had this 7 years ago, and it resolved after a while.  Saw a pulmonologist who said PFTs were normal.  Tried Ventolin without benefit IV today.

PULMO_3

LETTER

Date

Name

Address

City, State Zip

Re:

Dear Sirs:

This is regarding reimbursement of Mrs. (blank) for her prescription medicines.

Her medications at this time include Medrol 4 mg 1 tablet q.d.; Lasix 20 mg a day; Micro-K 10 mEq q.d., #28; as well as Zantac 150 mg p.o. b.i.d., #14; doxycycline 100 mg p.o. q.d. x 14 days; verapamil 80 mg, #30; Proventil inhaler 2 puffs q.i.d., 2 inhalers, 6 refills.

All of these drugs are prescription items and are vital to maintenance of her chronic emphysema is necessary to go back and insert the number of pills prescribed, as dictated.

PULMO_4

CONSULTATION

The above-captioned patient was examined by me on this date for the purpose of making an impartial determination regarding his ability to work and regarding the possible industrial origin of his disability.  I have reviewed some, but not all, of his medical records from the factory and have also examined documents shown to me by him.

He states that in 1979, he began to notice gradual onset of chronic tiredness and lack of normal pep and energy.  He states that his wife was aware of this before he was.  He took frequent naps and lacked sufficient pep for normal activities.  Later, he began to experience episodes of pressure or pain in the midchest, particularly at night, lasting minutes to hours.  These were not triggered by exertion or eating, nor were they associated with dyspnea or diaphoresis.  The pain did not radiate.  He had very little cough but did occasionally note wheezing in his chest.

His private physician evaluated him thoroughly but was unable to document any abnormality except mild hypertension, for which Inderal was prescribed.  He was evaluated at an environmental health clinic, and according to their report, a copy of which the subject showed me, he demonstrated bronchial hyperreactivity to toluene diisocyanate (TDI) as manifested by reduction in forced vital capacity (FVC) and one-second forced expiratory volume (FEV-1).  He also demonstrated bronchospasm in response to a methacholine challenge.  Radioallergosorbent test (RAST) was negative for IgE antibody to TDI.

A diagnosis of bronchial asthma with TDI sensitivity was made and Theo-Dur and Alupent were started, with some relief of symptoms.  Returned to work at the factory with the approval of his physician and with restrictions on exposure to TDI, asbestos, carbon black, and other noxious inhalants, and although he experienced no symptoms while at work, he had chest pain and dyspnea that night severe enough to require medical consultation.  He is presently taking Theo-Dur, Alupent, Bronkometer, Vanceril, and Aldoril.  He denies any history of asthma or wheezing before 1979.  He smoked 1 package of cigarettes daily from 1967 to 1980.

On physical examination, the subject is a normally developed and somewhat overweight white male appearing older than the stated age of 41 years.  He is alert, normally oriented, in good spirits, and cooperative.  He is eupneic at rest, both sitting and supine.  His skin shows a “farmer’s tan” of moderate intensity on the face, neck, and arms, and scanty acneiform eruption of the trunk.  The skin is pale, warm, and dry without cyanosis, striae, vascular lesions, or scars.

The head shows no gross deformity or lesions.  Scalp hair is normally distributed and gray.  The eyes are grossly normal, and the extraocular muscles are intact.  The pupils react to light.  The ocular fundi examined without mydriatic show no vascular changes or exudates.  The right ear is normal.  The left ear has a large central perforation of the tympanic membrane without inflammation or exudate.  The mouth and pharynx appear healthy.  The lower teeth are worn, and there is an upper partial denture in place.  The thyroid and cervical lymph glands are not palpable.  Carotid pulsations are full and equal, and neck veins are not distended.

The heart is regular at 100 without murmurs, clicks, S3 or S4, or clinical evidence of cardiomegaly.  A2 is equal to P2 in intensity.  The thorax is symmetrical without increase in anteroposterior diameter, and respiratory excursions are full and symmetrical without accessory respiratory muscle activity.  Bronchovesicular breath sounds are heard over both upper lung lobes on auscultation, and there are a few coarse sibilant expiratory rhonchi over the right middle lobe, not clearing with coughing.  The percussion note is normal throughout the chest.

The abdomen is slightly protuberant.  No masses, organomegaly, abnormal tenderness, or surgical scars are noted.  The extremities show grossly normal strength and mobility without tremor, edema, or clubbing.  Pedal pulses cannot be detected at this examination.  Cranial and spinal nerves are grossly intact.  Deep tendon reflexes are elicited with difficulty but are symmetrical.  Orientation, memory, judgment, and associations are unimpaired, and affect is appropriate.

Posteroanterior and left lateral chest radiographs taken today are not in full inspiration but show no abnormalities.

There is no cardiomegaly, and the lungs are free of infiltrates, fibrosis, calcifications, or space-occupying lesions.  The pleural margins are clear.  Pulmonary function studies done on this date show an FVC of 2.4 liter (48% of predicted), FEV-1 of 1.8 liter (48% of predicted), and FEV-1/FEC of 0.78 (101% of predicted).  Assuming maximal effort by the examinee, these studies show significant restrictive and obstructive abnormalities.

In summary, the examinee has mild exogenous obesity, a chronic perforation of the left tympanic membrane, and adult-onset reactive airways disease with demonstrated hyperreactivity to isocyanate vapor.  It is doubtful that the last-mentioned diagnosis adequately explains the full range of his symptoms.  There can be little doubt that he is abnormally sensitive to the irritant and bronchospastic effects of isocyanate.  It is not clear, however, what role his exposure to TDI played in the genesis of his pulmonary disease.  He continues to have bronchospastic symptoms, although he has not been near the factory for a year and a half.  This implies a chronic asthmatic diathesis not dependent on exposure to isocyanate vapor.  (It is known that in a small number of isocyanate reactors, a period of exposure to isocyanate may be followed by bronchiolitis with long-standing and progressive reduction in small airway caliber despite avoidance of any further exposure.)  Again, his FVC is only about half of what would be predicted for a man of his height and age.  This is hard to reconcile with the normal chest films, which show neither reduction in thoracic volume nor destruction or infiltration of pulmonary parenchyma.

A clearer picture of his condition might be obtained by doing FEF25-75, blood gases, and ventilatory and perfusion lung scans.  The scans have apparently been done in the past but with equivocal results.  On the basis of information available to me, I cannot say that this man’s present symptoms definitely are or definitely are not due to TDI exposure.  I would not consider the subject disabled for gainful employment.

PULMO_5

EMERGENCY ROOM REPORT

HISTORY OF PRESENT ILLNESS:  Patient is a 1-year-old female who has been congested for several days.  The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago.  Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving.  Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION:  Physical examination in the ER (showed an alert child in moderate respiratory distress.  Respiratory rate was 40, pulse 120, temperature 99.6.  HEENT was within normal limits.  Neck was positive for mild to moderate stridor.  Chest showed a diffuse inspiratory and expiratory wheezing.  No rales were noted.  Heart showed regular rhythm without murmur, gallop, or rub.  Abdomen was soft, nontender; bowel sounds normal.  Extremities are within normal limits.  Viewing the chest wall, patient had subcostal-intercostal retractions.

The child was sent for a PA and lateral chest x-ray to rule out pneumonia.  No pneumonia was seen on the films.

It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3h.  The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES

1.  Acute laryngeal-tracheal bronchitis.

2.  Bronchial asthma.

PULMO_6

CHART NOTE

The patient first presented with a respiratory infection and a 6-month history of progressive shortness of breath and 35-pound weight loss, and a left lung mass was noted.  Chest x-ray showed a cavitary left lower lobe lung mass, left hilar mass, and left pleural effusion.  CT of the chest showed a mass with mediastinal invasion and adrenal metastases.  He was also noted to have a 10-cm abdominal mass, and fine-needle aspiration of this revealed small-cell carcinoma, well differentiated.  Bronchoscopy showed an endobronchial lesion with 95% obstruction of the left main stem carina with extrinsic compression of the distal trachea on the left and right, with left vocal cord paralysis.  Cytology was also positive for small-cell carcinoma.

PHYSICAL EXAMINATION:  Vital signs include blood pressure 176/90, pulse 96, temperature 96.2, respiratory rate 20 per minute.  Weight 184 pounds.  General examination reveals a well-nourished, well-developed white male in no apparent distress.  Chest examination reveals decreased breath sounds in the lower one-third of the left lung field with dullness to percussion and end-inspiratory wheezes on the left. COR showed regular rate and rhythm without gallop or rub.  Grade 2/6 systolic ejection murmur at the lower left sternal border.  Abdomen is soft, nontender, bowel sounds present.

DIAGNOSES

1.  Extensive small-cell carcinoma of the lung.

2.  Metastases to the brain, abdomen, adrenals, and mediastinum.

PULMO_7

HISTORY AND PHYSICAL EXAMINATION

This 53-year-old male was evaluated by me in the emergency department on the above date, complaining of progressive shortness of breath and weakness.  He allegedly had been treated some 1 week prior for a right-sided pneumonia, being placed at that time on tetracycline 250 mg q.i.d., promethazine 6.25 mg every 4 hours, and Tylenol 1 every 3 to 4 hours as needed for temperature.  Historically, he has been coughing, nonproductive in nature, and has been experiencing fever and chills.  He had taken a Tylenol approximately an hour and a half prior to this evaluation.  He also has been experiencing poor appetite.

PHYSICAL EXAMINATION

VITAL SIGNS:  Physical assessment reveals his respiratory rate to be 48 per minute, pulse of 112, temperature 99.8, and a blood pressure of 150/80.

GENERAL:  General assessment reveals him to appear somewhat dehydrated, characterized by having dry mucous membranes.  NECK:  There is no nuchal rigidity.  ENT:  Ears, nose, and throat examination was otherwise unremarkable.

HEART:  His heart rate was regular and rapid without any definite murmurs, S3, or S4.

LUNGS:  Lungs were noted to have rales in the anterior and posterior inferior aspects with decreased breath sounds noted to those areas.  His left lung fields were within normal limits.

ABDOMEN:  His abdomen was soft, nontender, with bowel sounds.

GENITALIA/RECTAL:  Genital and rectal examinations were deleted.

EXTREMITIES:  His extremities were found to be free of any exanthematous changes.  His nail bed color was considered satisfactory.

PLAN:  While in the emergency department, multiple diagnostic studies were performed, including a CBC which revealed a white blood count of 18,800, 83 segs, 4 bands, 7 lymphs.  Arterial blood gas revealed a pH of 7.46, PC02 of 40, and a PO2 of 65.  Additional studies pending at this time were a Panel A and a sputum culture and sensitivity.  Chest radiograph obtained and initially interpreted by me revealed consolidative change involving the entire right lower lobe.

IMPRESSION:  Right lower lobe pneumonia refractory to outpatient therapy.