1. NYU Medical Grand Rounds Clinical Vignette Caprice Cadacio, MD PGY-2 May 2, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 54 year-old man with daily wheezing since age 21. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. 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. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination Obese, in no acute distress Vital Signs: 155/95, 72P, O 2 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: within normal limits, without peripheral eosinophilia Basic Metabolic panel: within normal limits Hepatic panel: within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Other Studies Chest X-Ray: flattened diaphragms, clear lung fields, no pleural effusion U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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 Working diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Lung function testing U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Pre bronchodilator % predicted Post bronchodilator % predicted % change FVC4376 FEV 1 265297 FEV 1 /FVC4955 TLC96 RV184 Flow volume curve Severe airway obstruction with large, but incomplete response to bronchodilator. Normal total lung capacity and increased residual volume consistent with airtrapping Predicted Pre bdPost bd

12. 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. Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. 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 Clinical Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Severe-persistent asthma, uncontrolled Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS