Read the following case study and answer the questions thatfollow. Submit your answers to this Dropbox.
The Case of the Coughing Housewife
Jessica, a fifty-nine year old mother of four, moved from aranch in Colorado to Los Angeles, after the death of her husband,to be closer to her oldest son and his family. She has been in LosAngeles for 18 months and has noticed that she is experiencingshortness of breath which has worsened over the last six months.For the last week, she has been coughing and bringing up yellowmucus. She also noticed swelling in her ankles so she decided tovisit a physician about her condition.
Jessica's family and medical history include a negative historyof asthma or allergies, lack of occupational or home exposure toasbestos, a previous smoking history (one package of cigarettes perday between the ages of 16 and 52), episodes of bronchitis, treatedwith antibiotics on an outpatient basis, and a positive history ofheart disease (father at 52 and brother at 56). Jessica has nohistory of serious illness, including heart disease, and her weightis within five pounds of her \"desired\" weight. She usually coughsin the morning to \"clear her throat\", but there is usually only asmall amount of white mucus.
Her nurse practitioner conducts a general physical examinationwith the following results. Jessica's skin is normal (no rashes orcyanosis) and her nervous system is functioning normally. Her bodytemperature was 98.4°F while her pulse was regular at 95 beats perminute with an occasional premature beat. Jessica's blood pressurewas within normal limits, however her jugular veins were slightlydistended. Her respiratory rate was 28 breaths per minute; shebreathed with pursed lips and used her accessory respiratorymuscles more than would be expected. Jessica presented with abarrel chest and mild dyspnea when climbing onto the examinationtable. When listening to her breathing, the nurse practitionernoticed that Jessica had prolonged expiration accompanied byexpiratory wheezes. Evaluation of her abdomen indicated no massesor tenderness, but she presented with both hepatomegaly andsplenomegaly. All of her extremities were normal with the exceptionof bilaterally pedal edema.
Based on these results, the nurse practitioner suspected apulmonary disorder and, after consultation with a physician,ordered laboratory tests (blood and sputum), spirometry and chestx-rays. The results of the laboratory tests were as follows: plasmabicarbonate = 38 mEq/L, hematocrit = 49%, white blood cell count =9000, pH = 7.38; PaCO2 = 56, and PaO2 = 54. Analysis of the sputumsample indicated the presence of epithelial cells,polymorphonucleocytes and gram positive diplococci. Jessica's 1second forced expiratory volume (FEV1) was 1.5 L/sec and her forcedvital capacity (FVC) was 4 L. These values were 40% and 83% ofnormal, respectively. Results of the chest x-ray indicated scarringand hyperinflation of the lungs.
The results of these tests coupled with the physical examinationand history lead to a diagnosis of emphysema. Jessica wasprescribed antibiotics for the infection and oxygen by nose as wellas a β2-agonist nebulizer as an acute treatment and requested tostay for observation and stabilization. After Jessica's conditionwas stabilized she was discharged and given a prescription for aninhaler containing a β2-agonist to be used as needed. She was alsoencouraged to exercise regularly and follow the nutritionalguidelines she was given. Jessica was also informed that if thesymptoms either worsened or did not lessen within the next week, toreturn and her treatment would be reevaluated and would possiblyinclude nocturnal oxygen and an inhaler containingcorticosteroids.
Questions:
- What risk factors and symptoms did Jessica present with priorto the physical examination that suggested a pulmonarydisorder?
- How did the physical examination, chest x-ray, and spirometryconfirm this hypothesis?
- Identify the muscles involved in respiration.
- How are these muscles responsible for the process ofventilation?
- If her condition does not progress, why would corticosteroidsbe used in the inhaler?
