CHRONIC OBSTRUCTIVE PULMONARY DISEASE

History of Present Illness

J.T. is a 61 yo man with COPD who presents to the emergency room with a three-day history of progressive dyspnea, cough, and increased production of clear sputum. He usually coughs up only a scant amount of clear sputum daily, and coughing is generally worse after rising in the morning. The patient denies fever; chills, night sweats, weakness, muscle aches, joint aches; and blood in the sputum. He treated himself with albuterol MDI, but respiratory distress increased despite multiple inhalations. Upon arrival at the emergency room, there were few breath sounds heard with auscultation, and the patient was so short of breath that he had difficulty climbing up onto the examiner's table and completing a sentence without a long pause. He was placed on 4 L oxygen via nasal cannulae and given nebulized albuterol treatments.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Past Medical History

• History of mental illness as a young adult; one suicide attempt at age 20
• HTN X 10 years
• COPD diagnosed 6 years ago
• Left lateral malleolus and first metatarsal fracture repair 17 months ago
• Occasional episodes of acute bronchitis treated as outpatient with antibiotics
• Mild CVA 4 months ago, appears to have no residual neurologic deficits
• (-) history of TB, asbestos exposure, occupational exposure, heart disease, or asthma

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Family History

• Father died from lung cancer
• Mother is alive, age 80, also has COPD and is being treated with oxygen
• One sister, developed heart disease in her 50s
• One daughter and three grandchildren, alive and well

Social History

• Patient is a recently retired beef products worker
• Married once and divorced at age 35, has not remarried
• Lives with elderly mother
• 2 pack/day Camel smoker for 37 years; has cut back to 5 cigarettes/day since he was diagnosed with COPD and is now willing to consider complete smoking cessation
• History of excessive alcohol use; has become a social drinker in last 15 years

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Review of Systems

• Denies recent weight loss but has lost 25 pounds during past 7 years
• Denies progressive fatigue, loss of libido, morning headaches, and sleeping problems

Medications

• HCTZ 25 mg po Q AM
• Amlodipine 5 mg po QD
• Fluticasone 100 mcg po BID (oral inhalation)
• Albuterol 180 μg MDI 2 inhalations QID PRN
• The patient has been compliant with his medications. However, he admits that he does not like to use ipratropium because it causes "dry mouth" and makes him feel "edgy."

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Physical Examination and Laboratory Tests

General Appearance

• Alert, thin, weak-appearing white male, who is somewhat improved and appears more comfortable after receiving oxygen and bronchodilator therapy

Vital Signs

See Patient Case Table 14.1

Patient Case Table 14.1 Vital Signs
BP                      165/95	RR               32 and labored	HT      5'10"
P                        110 and regular	T                 97.9°F	WT     120 lbs

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Skin

• Cold and dry
• (-) cyanosis, nodules, masses, rashes, itching, and jaundice
• (-) ecchymoses and petechiae
• Poor turgor

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Head, Eyes, Ears, Nose, and Throat

• PERRLA
• EOMs intact
• Eyes anicteric
• Normal conjunctiva
• Vision satisfactory with no eye pain
• Fundi without AV nicking, hemorrhages, exudates, and papilledema
• TMs intact
• (-) tinnitus and ear pain
• Nares clear
• (+) pursed lip breathing
• Oropharynx clear with no mouth lesions
• Yellowed teeth
• Oral mucous membranes very dry
• Tongue normal size
• No throat pain or difficulty swallowing

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Neck and lymph Nodes

• Neck supple but thin
• (+) mild JVD
• (-) cervical lymphadenopathy, thyromegaly, masses, and carotid bruits

Chest and Lungs

• Use of accessory muscles at rest
• “Barrel chest" appearance
• Poor diaphragmatic excursion bilaterally
• Percussion hyper-resonant
• Poor breath sounds throughout
• Prolonged expiration with occasional mild, expiratory wheeze
• (-) crackles and rhonchi
• (-) axillary and supraclavicular lymphadenopathy

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Heart

• Tachycardic with normal rhythm
• Normal S1 and S2
• Prominent S3
• No rubs or murmurs

Abdomen

• (+) hepatosplenomegaly, fluid wave, tenderness, and distension
• (-) masses, bruits, and superficial abdominal veins
• Normal BS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Genitalia and Rectum

• Penis, testes, and scrotum normal
• Prostate slightly enlarged, but without nodules
• Heme (-) stool
• No internal rectal masses palpated

Musculoskeletal and Extremities

• Cyanotic nail beds
• (-) clubbing
• 1 + bilateral ankle edema to mid-calf
• 2 + dorsalis pedis and posterior tibial pulses bilaterally
• (-) spine and CVA tenderness
• Denies muscle aches, joint pain, and bone pain
• Normal range of motion throughout

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Neurological

• Alert and oriented
• Cranial nerves intact
• Motor 5/5 upper and lower extremities bilaterally
• Strength, sensation, and deep tendon reflexes intact and symmetric
• Babinski downgoing
• Gait steady
• Denies headache and dizziness

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Laboratory Blood Test Results

See Patient Case Table 14.2

Patient Case Table 14.2 Laboratory Blood Test Results
Na                    147 meq/L	Plt                                                  160 X 103/mm3	Bilirubin, total                     0.3 mg/dL
K                      4.1 meq/L	WBC                                              9.1 X 103/mm3	PT                                     14.2 sec
Cl                     114 meq/L	PMNs(Polymorphonuclear)           62%	Alb                                      ;4.0 g/dL
HCO3               25 meq/L	Lymphs                                          27%	Protein, total                   6.8 g/dL
BUN                  29 mg/dL	Eos                                                 3%	Alk Phos                             78 IU/L
Cr                    1.1 mg/dL	Basos                                             1%	Ca                                      8.8 mg/dL
Glu, fasting       98 mg/dL	Monos                                            7%	PO4                                    3.5 mg/dL
Hb                    19.3 g/dL	AST                                               14 IU/L	Mg                                     2.5 mg/dL
Hct                   55%	ALT                                                31 IU/L	AAT                                   137 mg/dL

Note: Normal values, please refer to Laboratory Values posted on Canvas

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Arterial Blood Gases

• pH            7.32
• PaO₂        65 mmHg
• PaCO₂     54 mmHg
• SaO₂        90%

Note: Normal values, please refer to Laboratory Values posted on Canvas

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Pulmonary Function Tests

• FEV1 = 1.67 L (45% of expected)
• FVC = 4.10 L (85% of expected)
• FEV1/FVC = 0.41 (expected = 0.77)

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chest X-Ray

• Hyperinflation with flattened diaphragm
• Large anteroposterior diameter
• Diffuse scarring and bullae in all lung fields but especially prominent in lower lobes bilaterally
• No effusions or infiltrates
• Large pulmonary vasculature

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Medical Abbreviations

AAT        alpha-1-antitrypsin	BS              bowel sound
COPD    chronic obstructive pulmonary disease	CVA           cerebrovascular accident (stroke)
EOM       extra-ocular movements (or muscles)	HCTZ         hydrochlorothiazide
HTN       hypertension	FEV1          forced expiratory volume in one second
FVC       forced vital capacity	JVD            jugular venous distension
MDI        metered-dose inhaler	PERRLA    pupils equal, round, and reactive to light and accommodation
TB          tuberculosis	TM             tympanic membrane
AAT          alpha1-antitrypsin

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations

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