A case study on respi

Patient’s Profile

 Informant: Wife and Son

V.C., 78 year old, male, married, R.C., from Turod Sur, Cordon Isabela was admitted for the 3rd time at
FMMC last November 13, 2020 due to shortness of breath.

Past Medical

FMMC 2018(4 hospital days) Acute gastroenteritis

FMMC September 27-octuber 3 2020 COPDIAE; pulmonary mass
(7 hospital days probably malignant, primary
vs. metastatic

(+) Hypertension
(+) PTB, 6 mo. DOTS, 2018
(+) COPD
(+) Prostatic adenocarcinoma, Jan. 2019 (s/p TURP)
(-) Diabetes mellitus
(-) Heart disease
(-) Liver disease
(-) Kidney disease
(-) Thyroid disease Unknown immunization status

Family History
(+) DM, both sides of the family
(+) HPN, mother and siblings
(-) Bronchial asthma
(-) Thyroid disease
(-) Kidney disease
(-) Heart disease
(-) Liver disease
(-) Malignancy

Personal and Social

Non-alcoholic beverage drinker.
(+) 60 pack-year smoker, stopped 3 years ago.
(-) Illicit drug use
(-) Allergy to food or drugs Unemployed

History of Present Illness

5 months PTA (+) Findings of Pulmonary mass on CXR. No further evaluation was done. Offered chest CT
scan with contrast, but family members refused. Possibility of an underlying malignancy was not
disclosed to the patient per family members’ request.

10 weeks PTA (+) Productive cough, with whitish sputum (+) Occasionally blood streaked (+) Pleuritic
chest pain Consult: NAC 600mg tab, 1 tab in ½ glass H2O, to drink OD Levocetirizine+Montelukast
10/5mg, 1 tab ODHS Prednisone 10mg tab BID x 7 days Levodropropizine 10ml TID Doxofylline 200mg
tab BID

9 weeks PTA No relief of symptoms. (+) Loss of appetite. (+) Weight loss, 5kg in 2 months.

8 weeks PTA Admitted at fMMC. Discharged after 7 hospital days. Final diagnosis: COPDIAE; Pulmonary
mass probably malignant, primary vs. metastatic. Chest x-ray: Previous x-rays reviewed and compared.
There is interval increase in the diffuse reticular opacities seen in both lungs. Findings may be due to
pulmonary metastasis.

1 week PTA (+) Cough with productive whitish sputum. (+) Shortness of breath.

Few Hours PTA Increased severity of shortness of breath prompted consult at the ER, hence, admission.

Admitting Physical Examination

 GENERAL SURVEY Conscious, coherent, oriented to time place and person, not in respiratory distress,
with the following vital signs: BP: 120/80 mmHg HR: 81 bpm RR: 26 cpm T O: 37.8OC  SKIN Warm, with
good turgor & mobility, no lesions, no jaundice.

 HEENT Anicteric sclera, pinkish palpebral conjunctiva, no tonsilopharyngeal swelling, (+) cervical
lymphadenopathy, no neck vein engorgement

 CHEST & LUNGS Inspection: Thorax is symmetric with good expansion. Palpation: Decreased tactile
fremitus L. mid to base. Percussion: Dull percussion on L. mid to base, resonant RLF. Auscultation:
Bronchovesicular on L. mid to base, Vesicular on other lung fields, no rales appreciated, (+) wheezes RLF,
(-) rhonchi.

 CARDIOVASCULAR Adynamic precordium, normal rate, regular rhythm, (-) murmur.

 EXTREMITIES (-) gross deformities, (-) cyanosis, (-) clubbing, (-) edema, full equal pulses.

 ABDOMEN Flabby, normoactive bowel sounds, non-tender, no mass palpated.

 Back Spine at midline, no deformity.

 CNS Within normal limits.

Admitting Impression
 Health-care associated pneumonia;
 Recurrent pleural effusion probably 2O to malignancy;
 COPD in acute exacerbation;
 Hypertension, controlled;
 Anemia of chronic disease;
 Prostate adenocarcinoma.

DATE OF ADMISSION CBC

HEMOGLOBIN 12.3 (LOW)
HEMATOCRIT 37.9
WBC 21.94 (HIGH)
NEUTROPHILS 85.5 (HIGH)
LYMPHOCYTES 7.85
MONOCYTES 5.45
EOSINOPHILS 0.2
BASOPHILS 1.01
MCV,MCH,RDW NORMAL
PLATELETS 411

11/13/2020 CHEMISTRY
Na 137.3
K 3.73
BUN 15.41
creatinine 1.08
CT,BT Normal
Total protein 59 g/L (low)
LDH 624 (high)
albumin 3.7
PSA 1.5

Day of Admission
Imaging: CXR PA/L: There is near total opacification of the Left lung. Impression: Massive effusion. UTZ
of L. Hemi thorax: Approximately 450-500 cc of free pleural fluid in the dependent portions of the L.
hemi thorax. There is compressive atelectasis of the visualized lung segments. Impression: Moderate L.
pleural effusion with lower lobe atelectasis. S/P UTZ guided thoracentesis L. (+) dark yellow fluid aspirate
(480 cc). Pleural fluid analysis reveals exudative characteristics.

Other laboratories: Urinalysis: Normal Sputum GS: Gram (+) Cocci in singly. Sputum CS: Sputum AFB: (-) x
2 specimens ABG: Compensated metabolic alkalosis with adequate oxygenation. ECG: ST, NA, NSST-T
wave changes, isolated PACs Medications: Piperacillin-Tazobactam 4.5gm IV q8 Hydrocortisone 100mg
IV q8 Salbutamol+Ipratropium nebulization q8 Doxofylline 200mg tab BID Levocetirizine+Montelukast
10/5mg tab ODHS Bisoprolol 5mg, ½ tab OD Telmisartan 40mg tab OD Atorvastatin 10mg tab ODHS

1 st – 3 rd Hospital Day Chest CT with Contrast: Mixed attenuating, heterogenously enhancing, large
mass, almost replacing the entire L. upper lobe, with hilar extension encasing the vessels and L.
mainstream bronchus. Some areas of necrosis are also noted. Measures 20x13x12 cm. Impression: L.
upper lung mass, with associated findings and metastatic features.

4 – 8 th Hospital Day Repeat Chest UTZ: 150-200 cc L. lower lung pleural effusion with associated
atelectasis. Follow-up Chest UTZ: Increased L. lower lung pleural effusion. s/p UTZ guided thoracentesis:
dark, iced tea colored fluids aspirated (950 cc) CT guided fine-needle aspiration biopsy of L. upper lung
mass: Positive for malignant cells. Compatible with Squamous Cell Carcinoma of the lungs.

9 th Hospital Day Started systemic chemotherapy (First cycle) Gemcitabine 1600mg IV OD For cycle 1
week 2 of chemotherapy on Nov. 30, 2018.

10 - 17th Hospital Day Palliative care was continued. TPN: Kabiven 1400 kcal x 24H. Piperacillin-
Tazobactam 4.5gm IV q8, completed 10 days. Recurrence of pleural effusion, L.
Offered palliative radiotherapy. Home against medical advise.

Final diagnosis: Squamous cell lung CA stage 4 (liver, bone metastasis). Prostate adenocarcinoma.