University of Luzon

Perez Blvd. Dagupan City

College of Nursing and Midwifery

CASE STUDY
Of

Chronic Bronchitis

PATIENT’S PROFILE
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery

Name: Mr. A.R

Address: Polong Bugallon, Pangasinan
Age: 55 y/o
Birthdate: July 21, 1965
Birthplace: Lingayen, Pangasinan
Gender: Male
Status: Married
Nationality: Filipino
Religion: Catholic
Occupation: Auto mechanic
Chief Complaint: “I’m short of breath; I can’t stop coughing.”

PAST HISTORY
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery

Mr. A.R has been treated for high blood pressure, and pneumonia. He
has been treated for similar episodes of coughing and shortness of breath
during the past two years. He was hospitalized because he drinks too much
of alcohol and his pancreas acted up. A previous physician gave him
nitroglycerin. He smokes 1-2 packs of cigarettes per day and has done so for
the past 35 years.

PRESENT HISTORY
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery
Mr. A.R is a 55 year old auto mechanic who presents with progressive shortness
of breath for the past several days. His problem began four days ago when he 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, "kalahati ng baso nilalabas kong ganito araw-
araw". 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
for more than a year.

PHYSICAL ASSESMENT
He is a stocky man who appears haggard, tired and anxious. He speaks with
difficulty, quickly becoming breathless. There is cyanosis which intensifies during
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery
coughing spells. Blood pressure is 140/90. Apical heart rate is 96/minute and regular.
Respiratory rate is 28/minute. Temperature is 37°C.

Head and Neck - reveals the use of accessory muscles during respiration. Jugular veins
are dilated to 5 cm with a prominent "A" wave.

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 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.

Heart - 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.

Abdomen - 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.

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

ANATOMY AND
PHYSIOLOGY
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery

The respiratory system consists of all the organs

involved in breathing. These include the nose, pharynx,
larynx, trachea, bronchi and lungs. The respiratory system
does two very important things: it brings oxygen into our
bodies, which we need for our cells to live and function
properly; and it helps us get rid of carbon dioxide, which is
waste product of cellular function. The nose, pharynx, larynx,
trachea and bronchi all work like a system of pipes through
which the air is funneled down into our lungs. There, in very
small air sacs called alveoli, oxygen is brought into the
bloodstream and carbon dioxide is pushed from the blood out
into the air. When something goes wrong with part of the
respiratory system, such as an infection like pneumonia, it
makes it harder for us to get the oxygen we need and to get
rid of the waste product carbon dioxide. Common respiratory
symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth.
From there, it travels down your throat through the larynx (or voice box) and
into the trachea (or windpipe) before entering your lungs. All these
structures act to funnel fresh air down from the outside world into your
body. The upper airway is important because it must always stay open for
you to be able to breathe. It also helps to moisten and warm the air before it
reaches your lungs.
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery

The Lungs
Structure:
The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body,
which we need for our cells to live and function properly, and to help us get
rid of carbon dioxide, which is a waste product. We each have two lungs, a
left lung and a right lung. These are divided up into 'lobes', or big sections of
tissue separated by ‘fissures' or dividers. The right lung has three lobes but
the left lung has only two, because the heart takes up some of the space in
the left side of our chest. The lungs can also be divided up into even smaller
portions, called bronnchopulmonary segments'. These are pyramidal-shaped
areas which are also separated from each other by membranes. There are
about 10 of them in each lung. Each segment receives its own blood supply
and air supply.

How they work:

Air enters your lungs through a system of pipes called the bronchi. These
pipes start from the bottom of the trachea as the left and right bronchi and
branch many times throughout the lungs, until they eventually form little
thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where
the important work of gas exchange takes place between the air and your
blood. Covering each alveolus isa whole network of little blood vessel called
capillaries, which are very small branches of the pulmonary arteries. It is
important that the air in the alveoli and the blood in the capillaries are very
close together, so that oxygen and carbon dioxide can move (or diffuse)
between them. So, when you breathe in, air comes down the trachea and
through the bronchi into the alveoli. This fresh air has lots of oxygen in it,
and some of this oxygen will travel across the walls of the alveoli into your
bloodstream. Traveling in the opposite direction is carbon dioxide, which
crosses from the blood in the capillaries into the air in the alveoli and is then
breathed out. In this way, you bring in to your body the oxygen that you
need to live, and get rid of the waste product carbon dioxide.
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery

PATHOPHYSIOLOGY

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

CBC:
 University of Luzon
Perez Blvd. Dagupan City
College of Nursing and Midwifery
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.

Chemistry:

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.

Chest x-ray and sputum culture results are pending.

Spirometry Results:

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

FVC = 1.7L, Predicted = 3.9 L, Percent of Predicted = 43%
EV1/FVC = 29%