Anatomy & Physiology
Sample Case Study

Case of The Man With Smoker's Cough

Harold Myers,a 58 year-old male, visited his internist with complaints of two months of progressive cough, hemoptysis, dyspnea, and confusion. He said that for years he had a chronic "smoker's cough" that was worse in the morning., During the last two months, however, his coughing progressed; Harold stated that he went into "coughing fits" that often made catching his breath difficult. He also noticed that his sputum was occasionally blood-tinged. Harold had become so short of breath recently that he got winded easily even when he cooked in the kitchen. These symptoms represented a dramatic change; Harold had been an active golfer for years and until two months ago he prided himself in still being able to walk an entire 18 holes. He also complained of some mild confusion. For example, he occasionally got lost while driving his usual route to work.

Past Medical History:
Significant for a hospitalization for Pneumococcal Pneumonia two years ago.

He had a 60 pack-year smoking history. (Pack-years are defined as the number of packs per day the person smokes multiplied by the number of years the person has smoked; Mr. Myers began smoking one and a half packs per day at the age of 18.)

Albuterol inhaler for occasional wheezing

Physical Exam was remarkable for the following:
Weight: 150 pounds, down from 170 pounds one year ago.
Height:5 feet 11 inches.
Temperature: 98.6. Pulse: 88. Respirations: 24. Blood Pressure: 140/88
Skin: Revealed a slightly bluish hue to his lips, nailbeds, and ears
Lungs: Revealed decreased breath sounds over the apex of the right lung.
Lymph Nodes: No lymphadenopathy
Neurological Exam: He was alert and oriented to person, place, and time. Testing for long-term memory revealed that he could not remember his birthday nor his wife's birthday. His cranial nerves were intact. He had no sensory, motor, or cerebellar findings.

Hint: Checking out these web sites might help you learn more.

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Answer the following questions about this case. You can list your sources with each question or you can indicate your sources in the space provided at the end of the questions. Remember to review the criteria used for grading the case studies as given on the CASE STUDIES INDEX page. Including too much in your responses is better than not enough.
1 What is a normal respiratory rate?  
A normal respiratory rate depends on the age of the individual. A normal respiratory rate in the newborn is 44 breaths per minute! That rate declines with aging. A normal respiratory rate in adults is about 14-18 breath per minute. Women have slightly higher rates than men. Respiration rates also vary with activity and emotional being. Physical exercise and stress most likely results in an increase in respiration rates. Decreases in respiration rates occur with decreases in physical activity. Temperature levels and oxygen or carbon dioxide levels can also affect respiration rates.

2 What is Bronchodilation?  
The smooth muscle lining the bronchioles has two major receptors on it: Beta 2 (stimulated by sympathetics) and ACh (stimulated by Parasympathetics). A beta 2 agonist is a drug that stimulates beta 2 receptors; it causes bronchodilation. Bronchodilation is an action that results in creating a larger lumen in the bronchioles effectively increasing air flow through the bronchioles. Bronchodilation is brought on by a relaxation of the smooth muscle tissue surrounding the bronchiole tubes.

3 Laboratory Data:
Serum electrolytes test revealed a sodium of 120 mEq/dl; the other electrolytes were normal
Hematocrit:58 percent
White blood cell count:8,000 white cells with 60 percent neutrophils, 32 percent lymphocytes, 5 percent monocytes, 2 percent eosinophils, and 1 percent basophils

Chest X-Ray:
CT of the brain:

Another very important laboratory value should be obtained in someone with dyspnea of this severity. What is this laboratory value?  

When an individual experiences dyspnea of this severity, the physician should test the arterial blood gases to examine the arterial partial pressure of oxygen, pH, and partial pressure of carbon dioxide. The PO2 and PCO2 help assess the adequacy of ventilation. As ventilation worsens in lung cancer, the PO2 will decrease and the PCO2 will increase. The pH is determined by the PCO2 as well as other acids (and bases) in the body. As lung disease progresses, the arterial pH declines due to CO2 retention.

4 Which lobe of the lungs appears to be abnormal?  
The right upper lobe appears to be infiltrated with tumor. However, a tissue specimen (biopsy) should be obtained to confirm the diagnosis and determine the type of cancer. Personal habits (smoking) histories and family histories can also assist in distinguishing between tumor and pneumonia. Distinguishing between tumors and pneumonia can be difficult. However, the clinical history is often helpful. Pneumonias often present more symptoms of fever, chills, and cough and can be treated most effectively with antibiotics.

5 Is there a single disease that can account for symptoms, physical exam findings, and laboratory abnormalities? Explain. (Hint: look up paraneoplastic syndromes)  
Harold Myers is suffering from small-cell carcinoma of the lung (also called oat cell carcinoma). The cancer is causing bronchial obstruction of the right upper lobe (clues to this diagnosis are his cough, dyspnea and hemoptysis, decreased breath sounds, and markedly abnormal chest x-ray). He is most likely hypoxic; clues to this diagnosis are his cyanosis and polycythemia. His tumor is secreting antidiuretic hormone, which is the cause of his paraneoplastic syndrome. His paraneoplastic syndrome is characterized by a syndrome of inappropriate ADH secretion (SIADH), which is causing his hyponatremia and confusion. Hypoxemia is another cause of confusion.

6 Discuss the importance of smoking in the etiology of lung cancer.

Lung cancer causes 30% of all cancer deaths in the USA and is the leading cause of cancer deaths in this country.. Cigarette smoking causes 85% of lung cancers. The average risk of developing lung cancer is increased 13-fold by active cigarette smoking. However, an exact figure is impossible to quote because the risk depends on the amount smoked. For example, the risk of developing lung cancer is increased about 10-fold for men who smoke one pack per day for several years, and about 25-fold for men who smoke two packs per day. Long-term exposure to second-hand smoke also increases the risk of developing lung cancer.

Cigarettes also contribute to the cause of laryngeal, oral, esophageal, bladder, kidney, pancreatic, stomach, and uterine cancer, as well as one type of leukemia.

List Your Sources
Tortora and Derrickson "Principles of A&P"
Nursing Drug Reference: Mosbey