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Contents | Director | One | Two | Three | Four | Topic | EKG | Rad 1 | Rad 2 Albany Medical Review - January 2002 |
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Case Report-
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Mark A. Rasmus MD, Albany Medical Center, Albany, NY G. Scott Worthen MD, National Jewish Medical and Research Center, Denver, CO
PRESENTING COMPLAINT The patient is a 34-year-old woman who presented for an evaluation of her life-long asthma. Her asthma was poorly controlled since childhood; her symptoms seemed to worsen over the past three years. Over that period she has wheezed daily, had numerous emergency department visits, required monthly visits to her physician and required daily prednisone. Her symptoms were minimal at night and were rarely exacerbated by exercise. The patient was particularly concerned about longer recovery periods between attacks. These attacks required hospitalization four times in the five months preceding referral. She was diagnosed with radiologically confirmed pneumonia three times in the year prior to referral. The patient was evaluated at National Jewish Medical and Research Center to confirm her diagnosis of asthma and to evaluate for atopy and other allergic triggers. Past medical history is significant for eczema. The patient reported allergies since childhood, with anaphylactic reactions to specific foods including nuts, fish and raw eggs. There is no history of aspirin sensitivity or nasal polyposis. She also has a history of gastroesophageal reflux disease diagnosed by endoscopy. She suffers from osteopenia and cataracts related to her chronic corticosteroid use. Her surgical history is remarkable for sinus surgery to correct her deviated septum as well as debulking of concha bullosa. Medications on admission included prednisone, fluticasone MDI, salmeterol diskus, albuterol MDI/ nebs, montelukast, theophylline, alendronate, calcium, lansoprazole and azelastine nasal spray. Family history is significant for a sister with asthma, one child with atopic dermatitis and both parents have allergic rhinitis. The patient is a lawyer, married
and living in a suburb of Phoenix with two children. She is a life-long
nonsmoker, and rarely drinks alcohol which does not exacerbate her
symptoms. She has no pets and she follows many hypoallergenic precautions
in her home.
PHYSICAL FINDINGS Physical exam revealed a blood pressure of 122/68, pulse of 82, respiratory rate of 14 and oxygen saturation of 97% on room air. Patient was a pleasant white woman
with a cushingoid facies. Her HEENT exam was significant for pale
nasal mucosa without polyps and no conjunctival erythema was noted.
Oropharyngeal exam was unremarkable without palpable lymphadenopathy.
Cardiac exam was normal. Her chest was symmetric and normal to percussion
as well as palpation. On ascultation her lungs had expiratory wheezes
that were most prominent over the sternal notch. The wheeze was
loudest with forced expiration. No crackles were noted and her inspiratory
to expiratory ratio was within normal limits. Her skin revealed
numerous ecchymoses predominantly on her lower extremities and striae
on her abdomen. Abdominal, neurologic and extremities exam were
normal.
References Jokinen K, Palva T, Sutinen S, Nuutinen J. Acquired tracheobronchomalacia. Annals of Clinical Research 1977; 9:52-57. Lavins BJ, Hamilos DL. Distal airway bronchomalacia resulting in severe obstructive airway physiology. Chest 1990; 97(2):489-91. Cohn J. Localized bronchomalacia presenting as worsening asthma. Annals of Allergy 1985; 54(2):222-23. Arakawa H, Webb RW. Imaging of Obstructive Pulmonary Disease. Radiologic Clinics of North America 1998; 36(1): 189-209. Stelio LM, Sterman DH. Interventional Pulmonology. New England Journal of Medicine 2001; 344(10): 740-749. Ferguson G, Benoist J. Nasal continuous positive airway pressure in the treatment of tracheobronchomalacia. American Review of Respiratory Disease 1993;147:457-61.
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30.01.2002 |
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