1. Build a problem list based on the Hx .  What diseases have a higher probability of causing these clinical problems in this patient, especially when cough and shortness of breath are present together?  What additional problems have you identified?    

• Acute bacterial respiratory infection
• Chronic bronchitis
• Shortness of breath
• Pain in chest
• Swelling of ankles
• Significant occupation
• Smoking
• Alcoholism
• Hypertension
• Coronary artery disease
• Recurrent infections

2. What is the basis for chronic bronchitis?  Do we have to consider other possibilities?   

Diagnosis of Chronic bronchitis is a consideration because he coughs and brings up sputum every winter for many years. We also need to consider Bronchiectasis. We will see whether there is any evidence for Bronchiectasis.

3. Is his occupation important? What are the risks of his occupation ?  

• Asbestos exposure/co factor for lung cancer with smoking/ Mesothelioma and other malignancies
• Accidents

4. Let us evaluate his physical examination findings. Explain the pathogenesis of the following clinical findings:

•  Cyanosis     
• Use of accessory muscles   
• Distended jugular veins  
• Increased A-P chest diameter   
• Decreased breath sounds  
• Wheezing  and Crackles
• Soft heart sounds
• Loud S₂ (P₂ )
• S₄
• Tachypnea
• Fever  
• Palpable Liver
• Enlarged prostate with nodules

• Cyanosis  poor ventilation causes decreased 0₂ (less 0₂ available to couple with hemoglobin); increased deoxygenated hemoglobin leads to cyanosis.  
• Use of accessory muscles of respiration: Respiration requires much more effort because of bronchial constriction and the need to breath at high lung volumes.
• Distended jugular veins  with "a" wave: Reflects elevated diastolic pressure and volume secondary to pulmonary hypertension. This finding coupled with a congested liver and pitting edema supports the diagnosis of heart failure.
• Increased A-P chest diameter  hyper resonant percussion and decreased excursion of the diaphragm: Reflects hyper inflated lungs.
• Decreased breath sounds  with hyper-resonance is the most important physical finding for emphysema. Decreased diaphragmatic excursion, prolonged expiration are common to all of the chronic obstructive lung diseases.
• Wheezing  rhonchi, and crackles: Reflect narrowed bronchial lumina secondary to inflammation and mucous.
• Soft heart sounds: Interposition of fluid (pericardial effusion) or Lung (hyper inflated lungs).
• Loud S₂ (P₂ and  S₄.  Changes is S₂: Splitting is caused by delay in closure of pulmonary valve (pulmonary hypertension). P₂ is accentuated with hypertension. 
• S₄: Reflects forceful right atrial contraction/altered ventricular wall compliance -- Lower left sternal border indicates it is originating from right ventricle. Pulmonary hypertension.

• Tachypnea (28/min): Increased respiratory rate is an attempt to compensate for poor ventilation (decreased O2 , increased CO2). It is also compensation for air trapping with the patient breathing at a very high lung volume.

• Fever: Reflects an acute infection superimposed on chronic bronchitis. Early pneumonia? Cytokines affect the thermoregulatory mechanism.

• Palpable Liver: Could be either due to CHF or hyper inflated lungs pushing the diaphragm down. Liver span will help you distinguish between the two.

• Enlarged nodular prostate. Suggests prostatic hypertrophy with a consideration for malignancy.

5. Now after physical examination let us revisit our problem list.

• Acute bacterial respiratory infection: Wheezing and crackles, Fever
• Chronic bronchitis: Wheezing and crackles,  AP diameter, Tachypnea, Cyanosis
• Shortness of breath: Tacypnea, Accessory muscles in action, CHF (Neck veins, Liver, Edema)
• Pain in chest: Not evaluated by physical examination.
• Pulmonary hypertension. S2, S4
• Emphysema: Decreased breath sounds, AP diameter, Hyperinflation, Soft heart sounds
• Obstructive defect: Wheezing
• Swelling of ankles
• Significant occupation
• Smoking
• Alcoholism
• Hypertension
• Coronary artery disease
• Recurrent infections

6. Let us proceed with investigations. Take each problem we have listed and determine what type of investigation will help us resolve them.

Sputum Gram stain, Spirometry, ABG, CXR, EKG, CBC, Chemistry

7. Correlate and explain the laboratory data in the context of our problem list. 

The total white blood cell count is mildly increased, showing an early shift to the left. An acute bacterial infection superimposed on the chronic bronchitis may account for these findings.

The hemoglobin and hematocrit are increased. The erythrocytosis is secondary to the hypoxemia of chronic obstructive pulmonary disease. The patient is also a heavy smoker.

"Routine" chemistries show hypercholesterolemia. ALT is elevated, probably reflecting chronic passive congestive and mild hypoxia of the liver.

Electrolytes: Hyponatremia is most likely due to CHF and atrial natriuretic factor, leading to relative dilution of sodium with fluid overload.

8. How do you interpret his ABG. 

Arterial blood gases reveal a chronic respiratory acidosis with complete compensation. There is hypoxia and hypercapnia. The hypoxia is due to poor V/Q matching due to severe COPD. 

• Compensated (pH is normal) respiratory acidosis
• CO2 is high hence respiratory
• bicarbonate is high (a renal compensatory effort)
• Hypoxia

9. How would you explain his hypoxia?

Hypoxia could be due to

• Hypoventilation
• High altitude (Low FIO2)
• V/Q mismatch
• Diffusion barrier
• Anatomical shunt

In him Hypoventilation and V/Q mismatch probably account for hypoxia. He obviously has alveolar hypoventilation as judged by arterial CO2. Since his A-a gradient is high we have to include V/Q mismatch as co factor for his hypoxia.

10. The results of the sputum culture are pending. What do you expect the results to be? What is the rationale, if any, for ordering sputum culture? 

A sputum culture would probably not be ordered routinely in COPD. The sputum culture would probably show mixed flora. A gram stain of the sputum might be a more helpful and economical first step. A sputum culture would be indicated if the first antibiotic failed to clear the infection. Probable organisms causing the respirator infection include Streptococcus pneumoniae, Hemophilus influenza, Branhamella catarrhalis.

11. Interpret his CXR? Describe any abnormalities and correlate with the clinical problem.  (close the window to return) 

The chest x-ray is ordered to rule out pneumonia. There is no evidence for pneumonia. The x-ray shows hyperinflation, low set diaphragm and possibly blebs. The transverse diameter of heart is increased.

12.  What is the nature of respiratory infection?  Does he have Pneumonia? Explain his chest pain.

• Yellow-green sputum: Pus cells are responsible for yellow color. Presence of pus cells indicates bacterial infection
• Fever
• WBC count and differential showing signs of bacterial infection. (Leukocytosis, shift to left)
• Pleuritic pain raises suspicion for pneumonia, however the CXR is reported normal.
• Purulent acute bronchitis should be the consideration
• We have to explain pleuritic pain on the basis of cough fractures of ribs or muscle bruising.

13. Explain the significance, if any, of the results of spirometry.  

The most important evidence is that FEV₁/FVC is decreased (normal >75%) and is severe (<40%)

The Spirometry results are consistent with an obstructive pattern of pulmonary disease. The forced expiratory volume in 1 second FEV₁ measures the average flow rate during the first second of the forced vital capacity (FVC) maneuver, FEV₁ declines in direct proportion with clinical worsening of airway obstruction.  It increases with successful treatment of airway obstruction. The percent of  predicted FEV₁ for a normal patient should not slip below 80%. He has severe obstructive defect.

14. Determine the rate, rhythm and axis of the patient's electrocardiogram. Describe any abnormalities and correlate with the clinical problem. (Close the window to return) 

The electrocardiogram show a rate of 80 BPM, normal sinus rhythm and right axis of (+137^o); there is right ventricular hypertrophy with strain. The R is greater than S in lead V1 and the T wave is inverted in leads V₁-V₂. Strain suggests ischemia during diastole in a hypertrophied wall. S waves are deep in the left precordial leads. There is borderline right atrial hypertrophy by voltage, especially noted in leads II and AVF.

Right ventricular hypertrophy is consistent with this patient's clinical problem. He has chronic obstructive pulmonary disease with secondary hypertension and consequent cor pulmonale. Make sure the students understand the pathogenesis of the atrial/ventricular hypertrophy. Also, they should understand the pathogenesis of secondary versus primary pulmonary hypertension.

15. What is your diagnosis based upon the data given in the history and physical examination and lab data. 

Acute bacterial bronchitis
Chronic Bronchitis
Pulmonary Emphysema
Obstructive defect
Hypoxic hypercarbic respiratory failure
Pulmonary hypertension
Congestive Heart Failure/Corpulmonale
R/O Cancer prostate

The symptoms seem to reflect primarily a pulmonary problem, although there also is a cardiac component. An elderly smoker with a chronic, productive cough presents with acute and significant dyspnea. He apparently experienced similar episodes in the past.  The physical findings in an elderly smoker supports chronic pulmonary pathology with heart failure. He seems to have an infection of the respiratory tract. However he does not have pneumonia?  Physical signs point to pulmonary hypertension and right heart failure. His present episode is precipitated by acute bacterial bronchitis.

16. Describe the pathologic changes that you would expect to find in this patient. 

Chronic Bronchitis: mucous within bronchial lumina; chronic inflammation of the bronchial wall, marked increase in the size of the mucous glands (increase in Reid Index), patches of squamous metaplasia.  Acute bronchitis: mucosa/submucosal edema, inflammatory cells (also in sputum).

Emphysema: destruction of alveoli creating large air spaces scattered throughout both lungs. Scattered small pulmonary arteries showing smooth muscle hypertrophy. Hyper inflated lungs. 

Right ventricular/right atrial hypertrophy. Chronic passive congestion of the liver.

17. Identify the treatable problems in this patient.     

• Acute exacerbation of COPD
• Acute bacterial respiratory infection
• Chronic bronchitis
• Obstructive defect
• Pulmonary hypertension
• CHF/Corpulmonale
• Hypoxic hypercarbic respiratory failure
• Preventive measures
  • Significant occupational hazards
  • Smoking
  • Alcoholism

18.  Which Antibiotic will you select to treat  respiratory infection?  

19. How do you treat chronic bronchitis?   

20. What bronchodilators will you use? Explain the significance, if any, of the results of spirometry 

 21. How will you treat his Congestive Heart failure/Corpulmonale ? 

22. How will you correct Pulmonary hypertension?

 23. How will you correct his hypoxia?    

You need to have an understanding of the following statements. Administer oxygen like any medication with consideration for dose and method of delivery.

24.  How can you reduce his work of breathing? 

  25. What is the role for steroids? 

26. What can you do to treat Emphysema?  

27. What advise can you give regards his occupation?  

He probably has had Asbestos exposure.

With Smoking history he is at high risk for developing

• Lung cancer
• Other solid malignancies and
• Mesothelioma

He should be on annual surveillance program for early detection of these malignancies.

• Annual CXR
• Clinical evaluation and
• GI screening

 28. What is your plan for Smoking cessation?

• Advise him to stop smoking
• Nicotine patches/Gum
• Smoking cessation programs
• Support groups