Case 430N: 18 y/o woman with wheezing and a shortness of breath.

An 18 y/o African American woman college freshman without significant past medial history came to the student health clinic complaining of wheezing and shortness of breath. She says that her wheezing has been present intermittently over the past 6 months and seems to begin when she is around cigarette smoke or near animals but gradually clears when these exposures are removed. She has been markedly more symptomatic during the recent period of very cold weather. The wheezing does not seem to be related to exercise. This morning she awoke wheezing and while sitting in class this morning became gradually worse – her friends made her come into the clinic.

Past History: She recalls having had chickenpox as a child. She received the usual immunizations. She vaguely recalls getting shots for allergies as a child.

Social History: She denies any use of cigarettes, marijuana or other inhalational exposure. She has an occasional beer on weekends. Not sexually active.

Family History: Father and mother in good heath, no cancer or heart disease in the family. Two younger brothers in good health.

Meds: None

Allergies: Penicillin & Sulfa drugs (always been told to say that)

Physical Exam: A young well-developed (wd)/well-nourished (wn) female in moderate respiratory distress, BP 120/80, Pulse 90 and regular, Resp 20/min. Wt: 135 lbs; Ht: 5’ 6”
HEENT:​PERRLA, no sinus tenderness, no oral lesions.
Neck:​​Supple, no masses, no bruits
Chest:​Diffuse inspiratory and expiratory wheezes with mild prolongations of the expiratory phase.
Heart:​​PMI normal, no murmurs, suggestion of split-S2
Abdomen:​Soft, no organomegally, BS normal
Extremities:​No rashes, pulses equal and full.
Neuro:​​grossly normal

1. Develop a problem list and differential.

2. What further procedures or tests would you order now?

Chest X-ray read as normal
Spirometry results – Before and after Bronchodilator therapy

Predicted
Before
After
FVC
5.72L
4.50L(79%)
5.50L (96%)
FEV
4.47L
2.50L (56%)
4.20L (94%)
FEV1/FVC
0.78
0.56
0.76

CBC: Hct: 39%, WBC: 9,800/mm3 Differential: Neutrophils: 62%, Lymphs: 28%, Mono: 8%, Eosin: 2%.

3. What are the acute changes found by pulmonary function testing?

4. What are the various types of asthma?

5. What is the pathophysiology of airway obstruction in this disease?

6. What are the basic tenets of therapy for asthma?

7. What is status asthmaticus?

8. What are the classic morphologic changes of asthma?

9. What is the allergic bronchopulmonary aspergillius (ABPA) syndrome? What are the clinical manifestations? Describe the pathologic changes of ABPA?

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