This case of a patient with "obstructive" lung disease will test your understanding of history, physical and lab test interpretation in this disorder.

Chief Complaint: "I'm short of breath; I can't stop coughing."

History: Mr. O'Connor is a 62 y/o auto mechanic who presents with progressive shortness of breath for the past several days. His problem began four days ago when "I got a cold". His "cold" consisted of a sore throat, rhinorrhea and myalgia. His job forces him to work in the cold and damp air. At first he just felt tired but later he developed a cough* and shortness of breath. Initially, the cough was dry but within 24 hours of onset, it produced abundant yellow-green sputum. He states, "I cough up a cup of this stuff every day". He didn't think much of the cough because he continually coughs during the winter of each year. His wife states that he "hacks and spits up" every morning when he gets up from bed.

The shortness of breath has worsened so that he can hardly speak now. He also has pain in the left side of his chest when he coughs. He becomes very tired after walking up a flight of stairs of during a coughing spell. He denies hemoptysis, night sweats, chills, and paroxysmal nocturnal dyspnea. However, he does complain of swelling of his ankles: "I've had this for more than a year."

Mr. O'Connor has been treated for high blood pressure, pneumonias and infections of his hands. He has been treated for similar episodes of coughing and shortness of breath during the past two years. Once he was hospitalized because "I was drinking too much and my pancreas acted up." A previous doctor gave him nitroglycerin. He smokes 1-2 packs of cigarettes per day and has done so for the past 35 years.

Physical Examination: The patient appears much older than his stated age of 62 years. He is a stocky man who appears haggard, tired and anxious. He speaks with difficulty, quickly becoming breathless. There is cyanosis which intensified during coughing spells. Blood pressure if 146/82 mmHg. apical heart rate is 96 minute and regular. Respiratory rate is 28/minute. Temperature is 100.2o F.

Examination of the head and neck reveals the use of accessory muscles during respiration. Jugular veins are dilated to 5 cm. with a prominent "a" wave.

Examination of the chest reveals use of accessory respiratory muscles. The anterior-posterior diameter of the chest is increased. Respiration rate is increased; respiratory is regular and longer in expiration. Fremitus is decreased and the lung fields are hyper-resonant (diffusely) with percussion. Percussion also reveals decreased excursion of the diaphragm (bilateral). Breath sounds are diminished bilaterally. Coarse crackles, rhonchi and expiratory wheezes are heard bilaterally. Most of these sounds clear with coughing.

Examination of the cardiovascular system reveals soft heart sounds: S2 is split and louder than S1. The P2 component seems loader than A2 and is heard best at the base of the heart. An S4 is heard best along the left lower sternal border. A murmur is not detected.

The abdomen is round but soft. Bowel sounds are not heard. The liver edge is round, slightly tender and palpable 2 cm. beneath the right costar margin in the mid-clavian line. The prostate is enlarged and nodular on rectal exam.

Both feet show hallux valgus. There is pitting edema of the ankles.

Laboratory Tests:

The patient is first seen in the emergency room. The following data reflects the initial tests.

CBC: Leuokocyte count is 12,500/mm3, 58% neutrophils, 7% bands, 28% lymphocytes, 6% monocytes, 1% eosinophils. Hemoglobin = 19.8 g/dL; Hematocrit = 60%; Platelet count = 320,000/mm3.
Chem: Glucose 112 mg/dL (non-fasting); BUN 16 mg/dL, Creatinine 1 mg/dL; Cholesterol 240 mg/dL; Aspartate aminotransferase (AST) 18 U/L, Alanine aminotransferase (ALT) 32 U/L, Creatine kinase 72 U/L; Sodium 130 mEq/L, Potassium 4.8 mEq/L; Chloride 90 mE1/L, Bicarbonate 33 mEq/L.
ABGs*: pH 7.38, Pa 02 44 mmHg, PaC02 58 mmHg, HCO3 31 mEq/L.
Electrocardiogram:       Close the window to return to the case.

Chest x-ray PA and lateral views.   Close the window to return to the case.

Sputum culture results are pending.

The patient is hospitalized. Spirometry is performed. The flow volume loop and results are as follows: Close the window to return to the case.

FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17%
FVC = 1.7L, Predicted = 3.9L, Percent of Predicted = 43%
FEV1/FVC = 29%


Seller's Differential Diagnosis

Standard book of physiology

Text book of Medicine :Cecil's or Harrison