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CHIEF COMPLAINT: "I'm short of breath; I can't stop coughing.


HISTORY: Mr. O'Connor is a 62-year-old 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 or
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

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.


:\The patient appears much older than he 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 intensifies during coughing spells. Blood pressure is 146/82 mmHg. Apical
heart rate is 96/minute and regular. Respiratory rate is 28/minute. Temperature is 100.2 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; respiration is regular and longer
in expiration. Fremitus is decreased and the lung fields are hyperresonant (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 louder 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-clavicular line. The prostate
is enlarged and nodular on rectal exam.

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


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


Leukocyte 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.


Glucose 112 mg/dL (non-fasting); BUN 16mg/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 mEq/L, Bicarbonate 33 mEq/L.

Arterial Blood Gases:

pH 7.38, Pa O2 44 mmHg, Pa CO2 58 mmHg, HCO3 31 mEq/L.

Electrocardiogram: review attached sheet

Chest x-ray and sputum culture results are pending.

The patient is hospitalized. Spirometry is performed. The results are as follows:

FEV1 = 0.5L, Predicted = 2.9L, Percent of Predicted = 17%

FVC = 1.7L, Predicted = 3.9 L, Percent of Predicted = 43%

FEV1/FVC = 29%

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