CHIEF COMPLAINT: Patient is here for worsening problems with his breathing.
HPI:
Patient is a 41-year-old white male who developed asthma while on active duty in the Air Force in 2005. He was medically discharged due to his asthma. He attributes onset of his asthma to working with jet fuels and other chemicals in his work on the fuel line in the Air Force. Patient states his breathing has been getting progressively worse since 2005. At present he only uses an albuterol metered-dose inhaler, uses 1 inhalation up to about 6 times per day. He is reluctant to consider using other medications for his asthma. He used Advair in the past but states this caused mood changes, anxiety, sleeplessness, and also developed thrush. He also tried montelukast in the past and thinks he
had some type of adverse reaction to this, but states it didn’t seem to help. He may have tried some theophylline in the past but doesn’t really recall whether this was helpful or not. Patient is quite reluctant to consider using inhaled steroids or other conventional medications for his chronic asthma. He states he was concerned that the inhaled steroids could cause visual problems or blindness. Patient states he may have increased asthma symptoms with certain foods such as cheese or tomatoes. He does have daily symptoms and these will significantly worsened if he develops an upper respiratory infection or cold. He also complains of problems with his “neck going out of alignment”, and states that adjustment seems to help his asthma if it flares up. He notices increased symptoms with exercise, cold air, and may breathe better with warm humid air. He will also notice increased symptoms with smoke, dust, odors or perfumes. Symptoms are generally worse in the summer months. He is not usually limited with normal walking on his good days, but hat will have limitation of his asthma flares. He rides a bike regularly and usually doesn’t need to stop when riding his bicycle. Patient states he eats only organic foods, states he doesn’t feel as well and may have increased asthma symptoms if he eats “impure foods”. He has tried various herbal remedies for his asthma, and is currently taking some type of beef lung extract PNEUMOTROPHIN PMG for his asthma. He has had 1 hospitalization within the past 6 years since he established follow-up at the VA. He also has had 2 ER visits for asthma. He denies any history of pneumonia or recurrent bronchitis. He has not had allergy testing. He has a cat.
Past Medical History:
- Hypoxemia
- Chronic neck pain
- Asthma
- Allergic rhinitis
- Anxiety
Social History: Patient is single and lives alone. He is a high school graduate from California and is currently enrolled in college. He has no family in the area. Mother lives in Florida. He receives disability from the government for Asthma, chooses not to work.
Tobacco use: Never smoked cigarettes, states he did chew tobacco for a short time while in the Air Force. Admits to smoking marijuana on occasion.
Alcohol use: Denies alcohol use.
Family History: Patient’s grandfather died of leukemia. A grandmother died with an MI. Father has prostate cancer. A brother has asthma but less severe than him.
Childhood Illness: Allergy symptoms with some rhinitis. Denies asthma in childhood.
Occupation: The patient worked in fuel maintenance/aircraft fueling, had exposure to jet fuels and some chemicals while in the Air Force. As a civilian he did some work in a mortgage business, also did retail sales, and more recently is a student majoring in business.
Surgical Hx: Tonsillectomy in childhood, and BB removed from his right eye in the past.
Vaccinations: not current, has refused pneumovax in the past
Allergies: Allergies/ADR
Active Outpatient Medications Status
=========================================================================
1) OXYCODONE HCL 5MG TAB TAKE 1 TABLET (5MG) BY MOUTH ACTIVE THREE TIMES DAILY FOR 7 DAYS, THEN TAKE 1 TABLET
(5MG) TWICE A DAY FOR 7 DAYS, THEN TAKE 1 TABLET (5MG) DAILY FOR 7 DAYS FOR PAIN
Active Non-VA Medications Status
=========================================================================
- Non-VA ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL 2 PUFFS ACTIVE BY MOUTH FOUR TIMES A DAY IF NEEDED
- Non-VA MED MISCELLANEOUS PNEUMOTROPHIN PMG BY ACTIVE MOUTH DAILY
3 Total Medications
REVIEW OF SYMPTOMS
Weight loss of about 7 pounds over the past month, states his appetite has been reduced. Occasional headache, intermittent fatigue, some chronic neck and back pain, nocturia once per night which he attributes to drinking large amounts of fluid in the evening, allergic rhinitis usually worse in the spring months or if he eats cheese, All other negative
PHYSICAL EXAM
DATE/TIME TEMP PULSE RESP BP PAIN WEIGHT PO2 11/2/15 @ 1423 98 89 16 115/76 0 149.1 91
10/5/15 @ 1103 98.2 91 18 121/72 0 156 93
9/15/15 @ 1511 99 95 120/76 0 155.5 86
02 Assessment: 10/5/15
RA resting: 91%
RA with ambulation: 84%.
Ambulated on 2 lpm with PD regulator: 91%
Recommend home oxygen on 2 lpm via PD regulator (02 concentrator, metal tanks)
*Patient using albuterol mdi/svn 5+ times/day. Using 02 PRN, not with exertion or at night.
General: Alert adult white male, moderately thin, no acute distress
HEENT: Normocephalic, PERRLA, oropharynx unremarkable, no exudates or thrush
Neck: no lymphadenopathy or thyromegaly
Chest: Distant breath sounds bilaterally with fair airflow with prolonged expiratory phase, scattered low pitched expiratory wheezes bilaterally, airflow is symmetric, chest is diffusely hyperresonant to percussion.
Cardio: Moderately distant, RRR without murmurs or extra sounds, normal S1, S2, no S3 or S4, no JVD, carotid and radial pulses 2/4 bilaterally, no carotid bruits. No cyanosis, clubbing, or edema.
Abdomen: Soft, nontender, no hepatosplenomegaly or mass
GU/Rectal: Deferred
Skin: No apparent rash or lesions
Musculoskeletal: No active synovitis or inflammatory arthritis, no overt deformities
Neuro: No gross neurologic deficits
CHEST 2 VIEWS:
09/15/15 Significant hyperexpansion with bilateral flattening of the diaphragms, probably a few tiny calcified granulomas, has had hyperexpansion dating back to his initial chest film in 2011, but hyperexpansion is worse with fewer markings in his lung fields.
Chest CT scan:
9/24/2014 also demonstrates hyperexpansion without discrete changes of emphysema.
PFT: 2/28/2011
Pre Test
Post-Test No previous test. ATS criteria met. Good effort. Albuterol 1 puff for BDR. Pt requested only
1 puff given.
- PRE-BRONCH POST-BRONCH
| FVC (L) 5.81 5.74 99 6.68 115 16 FEV1 (L) 4.40 2.18 49 2.75 62 26 FEV1/FVC (%) 76 38 50 41 54 8 FEF 25-75% (L/sec) 4.60 0.73 16 1.14 25 56 FEF Max (L/sec) 10.42 4.16 40 4.82 46 16 FIVC (L) 5.67 4.04 -29 FIF Max (L/sec) 4.15 4.56 10 Expiratory Time (sec) 16.42 14.89 -9 |
Pred. Actual %Pred. Actual %Pred. %Chng. SPIROMETRY
LUNG VOLUMES
SVC (L) 5.81 5.98 103
IC (L) 3.82 3.56 93
ERV (L) 1.99 2.43 122 DIFFUSION
DLCOunc (ml/min/mmHg) 43.97 43.70 99
DL/VA (ml/min/mmHg/L) 5.69 5.10 90
VA (L) 7.73 8.58
Pre-bronchodilator spirometry demonstrates severe obstruction manifest by an FEV1 of 2.2 L, 49% of predicted along with severely reduced FEV1 percent ratio of 38%, with severely reduced flow rates. There is significant improvement following inhaled bronchodilator, the patient remains moderately obstructed. Single breath diffusion capacity and DLVA are both normal. Study is compatible
with severe obstruction due to asthma.
PFT: 10/27/2015
Pre-bronchodilator spirometry demonstrates normal FVC, severely reduced FEV1 of 1.5 L, 32% of predicted, and severely reduced FEV1 percent ratio 27%. Flow rates are also severely reduced. Following inhaled bronchodilator there is a 12% improvement in the FEV1 to 1.7 L, 37% of predicted. The FEV1 percent ratio remains severely reduced at 31%. Peak x-ray flow rate doesn’t change significantly. Lung volumes by plethysmography demonstrate mildly supernormal total lung capacity of
9.9 L, 128% of predicted. The residual volume is markedly increased at 4.8 L, 232% of predicted. RV/TLC ratio is severely increased at 48%, 179% of predicted demonstrating severe air trapping. Single
breath diffusion capacity is normal at 35.5, 95% of predicted. The DL VA is also normal at 94% of predicted.
LABS:
AMPHETAMINE/METHAMPHETAMINE NEG BARBITURATES NEG BENZODIAZEPINES NEG
CANNABINOIDS POS H COCAINE METABOLITES NEG OPIATES NEG
OXYCODONE NEG BUPRENORPHINE NEG
METHADONE NEG
| WBC | 11.0 H K/uL 4.3 – 10.9 |
| RBC | 5.54 M/uL 4.7 – 6.1 |
| HGB | 16.0 g/dL 13 – 18 |
| HCT | 48.5 % 39 – 51 |
| MCV | 87.6 fl 80 – 100 |
| MCH | 28.9 pg 26 – 33 |
| MCHC | 33.0 g/dL 32 – 36 |
| RDW | 13.0 % 11.5 – 14.5 |
| PLT | 233 K/uL 150 – 450 |
| NEUT % | 53.3 % 50 – 76 |
| LYMPH % | 30.8 % 20 – 40 |
| MONO % | 8.5 H % 1 – 8 |
| EOSINO % | 6.9 H % 0 – 6 |
| BASO % | 0.5 % 0 – 2 |
| NEUT # | 5.9 K/uL 2.0 – 6.8 |
| LYMPH # | 3.4 K/uL 1.0 – 4.0 |
| MONO # | 0.9 K/uL 0.2 – 1.0 |
| EOSINO # | 0.8 H K/uL 0.0 – 0.5 |
| BASO # | 0.1 K/uL 0.0 – 0.2 |
TRANSGLUTAMINASE IGA AB <2 U/mL 0 – 3
Comment: Negative 0 – 3
Weak Positive 4 – 10
Positive >10
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