Exam 1 Review
Cardiopulmonary Symptoms
Physical Examination
Clinical Laboratory Studies
WBC Count Differential
 A patient had been admitted to the
hospital for acute shortness of
breath. A CXR examination reveals
pneumonia and the patient’s
temperature is elevated. The CBC
shows an increased WBC of
15,000/mm3 with 75%
neutrophils but only 10%
lymphocytes. Given that the
normal lymphocyte differential is
20-45%, does the value of 10%
suggest a problem with lymphocyte
production by the immune system?
What type of pneumonia is
probably present in this case?
 The 10% differential for the
lymphocytes represents a relative
value. Because the total WBC is
markedly elevated, the 10% in
relative terms represents 1500
lymphocytes in an absolute value,
which is well within the normal
range. If the total WBC were
reduced to less than normal and the
differential demonstrated a
lymphocyte count of 10%, an
abnormal value would be present
and would suggest an
immunological problem. The
patient probably has bacterial
pneumonia given the elevated
number of neutrophils.
Water, Salt and CHF
 Why do patients who have CHF
need to adhere to a low-salt
diet?
 The volume of extracellular
water partially determines the
preload of the ventricle – Na+
is an important determinant of
extracellular volume. In CHF
the left ventricle has failed as a
pump, leading to pooling of the
blood in the lungs and venous
circulation. By restricting salt
intake, extracellular volume can
be reduced, allowing the heart
to function more effectively as a
pump. Diuretics are often used
to help reduce fluid volume.
Bedside assessment of the postoperative
patient
 The RT is called to the floor too see
a 54year old female who had
abdominal surgery 2 days ago. She
is currently complaining of
dyspnea. Her resting RR is 34 and
shallow. Her HR is 110. She is 5’
and weighs 185lbs. During the
brief interview, the RT identifies
that the dyspnea has gradually
increased over the last 12hrs and
increases with exertion. During
auscultation, the RT identifies
diminished breath sounds with
some fine late inspiratory crackles.
The remainder of the physical
examination is normal. What is the
most likely cause of this patient’s
dyspnea and what should be done?
 The findings indicate a loss of lung
volume as the cause of the sudden
dyspnea. The rapid, shallow
breathing; fine late inspiratory
crackles and history of recent
abdominal surgery suggest
atelectasis. The RT should verify
with a CXR and begin
hyperinflation therapy if confirmed
Sudden onset of chest pain
 The RT is called to the ED to see a
47year old man who came in with
anxiety and chest pain. He is
certain he is having a heart attack
and demands immediate treatment.
The attending MD is on his way and
asks the RT to assess in the
meantime. What do you do?
 Place the patient on oxygen, asks
him for details about the chest pain
 The pain is located laterally on the
left side and increases with each
inspiratory effort, vital signs are
normal except for a slight increase
in heart rate. What is the most
likely cause of the chest pain and
what should be done until the MD
arrives?
 In this case the pain is pleuritic, the
RT should continue oxygen therapy,
ensure the cardiac leads are
attached to rule out any heart
disease.
Evidence of Tissue Hypoxia
 The RT is called to the ICU to see a
new patient in septic shock. The patient
complains of having dyspnea and fever
for the last 3 days. His vital signs are:
HR 100, RR 24, BP 80/65, body temp
below normal. The patient is alert but
confused, and his sensorium has
deteriorated over the last 12 hours.
Auscultation reveals fine crackles in the
bases bilaterally and no murmurs or
gallop rhythm. There is no evidence of
cyanosis, pedal edema, or JVD.
Capillary refill is 3 seconds and his
extremities are warm to the touch.
What suggests that this patient has
hypoxia?
 The patient’s sensorium
shows that the brain is not
getting enough oxygen,
probably due to poor
circulation.
Terminology for Adventitious Lung
Sounds
 The RT is auscultating a
patient who has severe
pneumonia in the ICU .
He hears a low pitched
discontinuous sounds with
inspiration and expiration.
How should he document
these?
 Coarse crackles, indicating
that excessive airway
secretions are present.
Case Study 1
CBC
results
normal
WBC
19.5
4.5-11.5
 A 22 year old white woman is
RBC
4.2
4.2-5.4
Hb
10.6
11.5-15.5
brought to the ED by her mother
with chief complaints of cough,
fever, and normal BP. She has a
history of Down syndrome and
lives at home with her parents.
Initial examination reveals
tachycardia, tachypnea, and fever;
chest auscultations identifies
bronchial breath sounds and
inspiratory and expiratory coarse
crackles over the right lower lobe.
The admitting physician orders a
sputum Gram stain and culture,
CBC and chest x-ray. The initial
laboratory results are as follows:
Hct34.9% 38-47%
MCV
77.0
80-96
MCHC
30.4%
32-36%
WBC Differential
results
normal
Neutrophils 82%
40-75%
Lymphocytes
8%
Monocytes 4%
0-6%
Eosinophils 1%
0-6%
Basophils
0%
0-1%
Bands
6%
0-6%
20-45%
Gram Stain 2+ gram positive cocci;
1+ pus cells with many epithelial cells
Case study 1 solution
Leukocytosis is present and appears to be the result of an increase in the neutrophils consistent with a
bacteria infection (probably pneumonia). The slight increase in immature neutrophils (bands)
represents a left shift indicating stress on the bone marrow to release more neutrophils to fight the
infection. The relative decrease in the percentage of lymphocytes is caused by the absolute increase in
the number of neutrophils and is not an abnormality.
The RBC count is within normal limits; however the decreases in Hb, Hct, MCV, and MCHC are
consistent with a microcytic, hypochromic anemia. Further investigation is needed to identify the
cause, but iron deficiency anemia is a likely reason.
The Gram stain of the sputum sample indicates that is was heavily contaminated with secretions from
the mouth because many epithelial cells were present. The sample should be discarded and another
sputum sample obtained.
Common causes of pneumonia
Streptococcus pneumoniae
Staphylococcus aureus
Klebsiella pneumoniae
Haemophilus influenzae
Case Study 2
 A 65 year old woman arrives to the
ED complaining of severe shortness
of breath, weakness and cough. She
has a long history of COPD and 90pack year smoking history, She
currently admits to smoking
1pack/day. In the ED she appears
acutely and chronically ill and is
found to be using her accessory
muscles to breathe. She is cyanotic
and has decreased breath sounds
bilaterally. She is started on O2 by
NC and a CBC and electrolyte
determination is ordered. The
results are as follows:
CBC
results
normal
WBC
19.9
4.5-11.5
RBC
5.1
4.2-5.4
Hb
15.8
11.5-15.5
Hct
48.5%
38-47%
MCV
98.2
80-96
MCHC
31.6%
32-36%
WBC Differential
results
normal
Neutrophils
76%
40-75%
Lymphocytes 12%
20-45%
Monocytes
5%
0-6%
Eosinophils
4%
0-6%
Basophils
2%
0-1%
Bands
1%
0-6%
Na+
137
137-147
K+
4.8
3.5-4.8
Cl-
87
98-105
Total CO2
41
23-33
Electrolytes
Case study 2 solution
The increase in WBC suggests leukocytosis and appears to be the result of an
increase in the number of circulating neutrophils. This may be in response to a
bacterial infection or acute stress. The RBC count, Hb, and Hct are slightly
increased, consistent with polycythemia. These RBC differential findings are
consistent with secondary polycythemia typical for patient with a chronic lung
disease in which the arterial blood oxygen levels are persistently low. The
electrolyte values reveal a decreased serum Cl- and increased serum CO2. This
probably is related to the COPD and CO2 retention. Due to the increased
HCO3- the kidneys excrete more Cl- in an effort to maintain electrical neutrality.
Case Study 3
 A 27year old man has a CD4
count of 120. He is
concerned about his chronic
cough and sputum
production. The sputum has
been negative for white cells
and bacteria. A PPD skin test
was placed on his right
forearm 2 days ago and now
there is a 3-cm reddened area
and a 5mm nodule at the site.
Initial laboratory data results
are as follows:
CBC
results
normal
WBC
5.0
Neutrophils
70%
40-75%
Lymphocytes
20%
20-45%
Monocytes1%
0-6%
Eosinophils
4%
Basophils 0%
0-1%
Bands
5%
Hb
14
4.5-11.5
0-6%
0-6%
13.5-16.5
Hct
42%
40-50%
Sedimentation rate
40 (elevated)
Case study 3 solution
The low CD4 count suggest moderate immunocompromise most likely
caused by HIV. The elevated sedimentation rate suggests inflammation,
which could be caused by TB or other infection. The large area of redness
around the skin test site is not significant, but the nodule in this
immunocompromised patient indicates a TB infection. This patient’s CBC
is normal despite his chronic infection and because TB does not usually
cause an elevated WBC count. We anticipate the sputum cultures will be
positive in 6 weeks and a PCR test for TB bacilli in the sputum to be
positive.
Case Study 4
 A 20 year old man is
brought to the ED by
ambulance following a
MVC. He complains of a
stiff neck and left leg pain.
Although he is upset and
scared, he is conscious and
able to move all
extremities. Vital signs are
normal except HR-110.
His initial CBC is as
follows:
CBC
results
normal
WBC
14.9
4.5-11.5
RBC
5.1
4.2-5.4
Hb
15.0
11.5-15.5
Hct45.5% 38-47%
MCV
95.2
80-96
MCHC
33.6%
32-36%
WBC Differential
results
normal
Neutrophils 76%
40-75%
Lymphocytes
12%
Monocytes 5%
0-6%
Eosinophils 4%
0-6%
Basophils
2%
0-1%
Bands
1%
0-6%
20-45%
Case study 4 solution
The RBC and indices are all normal. The elevated WBC count
suggests possible infection, however the lack of fever and minimal
presence of band on the white cell differential suggests otherwise.
This is most likely a case of pseudoneutrophilia, where marginated
neutrophils are released into circulation as a result of sudden stress.
This type of neutrophilia is usually transient and resolves
spontaneously in a matter of hours.
Auscultation
List three reasons why patients with emphysema may have
diminished breath sounds.
2. Explain why patients with obstructive lung disease breathe with
a prolonged expiratory time.
3. Explain why atelectasis causes late inspiratory crackles as
opposed to early inspiratory crackles.
1.
What is this?
What is being examined?