CASE 2

A 52 year old man presents to your office for an acute visit because of
coughing and shortness of breath.He is well known to you because of multiple
office visits in the past few years for similar reasons.He has a chronic
“smoker’s cough”,but reports that in the past 2 days his cough has
increased,his sputum has changed from white to green in color,and he has
had to increase the frequency with which he uses his albuterol inhaler.He
denies having a fever,chest pain,peripheral edema,or other symptoms.His
medical history is significant for hypertension,peripheral vascular disease,and
2 hospitalizations for pneumonia in the past 5 years.He has a 60 pack year
history of smoking and continues to smoke 2 packs of cigarettes a day.

On examination,he is in moderate respiratory distress.He is temperature is

98,4˚F,his blood pressure is 152/95 mmHg,his pulse is 98 beats/min,his
respiratory rate is 24 breaths/min,and he has an oxygen saturation of 94 % on
room air.His lung examination is significant for diffuse expiratory wheezing
and a prolonged expiratory phase of respiration.There are no signs of
cyanosis.The remainder of his examination is normal.A chest x-ray done in
your office shows an increased anteroposterior (AP) diameter and flattened
diaphragms,but otherwise clear lung fields.
 KEYWORDS

 Man,52 years old

 Coughing
 Shortness of breath
 Chronic smokers
 Sputum green
 No fever,chest pain,peripheral edema
 Hipertension,peripheral vascular disease,ever pneumonia
 He has a 60 pack year history of smoking and continues to smoke 2 packs
of cigarettes a day.
 Temperature 98,4˚F
 Blood pressure 152/95 mmHg
 Pulse is 98 beats/min
 Respiratory rate is 24 breath/min
 Oxygen saturation wheezing
 No sign of cyanosis
 FRAME OF THEORY

Chronic obstructive pulmonary disease (COPD) is the name of a group of

chronic and slowly progressive respiratory disorders characterized by reduced
maximal expiratory flow during forced exhalation. Most of the airflow obstruction
is fixed, but a variable degree of reversibility and bronchial hyperreactivity may
be seen.COPD may coexist with asthma and, when abnormal airway reactivity is
present, differentiation between these disorders can be challenging.

GOLD Classification of COPD

Stage Characteristics 0: At risk

Normal spirometry

Chronic symptoms (cough, sputum production)

I: Mild COPD

FEV1/FVC ‹ 70%

FEV1 greater than or equal to 80% predicted

With or without chronic symptoms (cough, sputum production)

II: Moderate COPD

FEV1/FVC ‹ 70%

FEV1 greater than or equal to 30% to ‹80% predicted

 IIa: FEV1 greater than or equal to 50% to ‹ 80% predicted
IIb: FEV1 greater than or equal to 30% to ‹ 50% predicted

With or without chronic symptoms (cough, sputum production, dyspnea)

III: Severe COPD

FEV1/FVC ‹ 70%

FEV1 ‹ 30% predicted or FEV1 ‹ 50% predicted plus respiratory failure or clinical
signs of right heart failure

GOLD, Global Initiative for Chronic Obstructive Lung Disease; COPD, chronic
obstructive pulmonary disease; FEV1, forced expiratory volume in one second;
FVC, forced vital capacity; respiratory failure, arterial partial pressure of oxygen ‹
60 mm Hg with or without arterial partial pressure of carbon dioxide greater than
or equal to 50 mm Hg while breathing air at sea level.

Source: The GOLD Workshop Panel.[1]

 ANALYSIS

 Man,52 years old,Coughing,Shortness of breath,Sputum green

(There are signified that he has problem with his respiratory tract)
 Man,52 years old,hipertension,peripheral vascular disease,ever
pneumonia,chronic smokers
(Insrease the risk of COPD)
 He has a 60 pack year history of smoking and continues to smoke 2 packs
of cigarettes a day
(Increase the risk of COPD)
 No fever,chest pain,peripheral edema
(There are can eliminate diagnosa of heart disease)
 Temperature 98,4˚F (normal)
 Blood pressure 152/95 mmHg (normal)
 Pulse is 98 beats/min (normal)
 Respiratory rate is 24 breath/min (Abnormal:Takipneu)
 Oxygen saturation wheezing
(Increase the diagnosa of asthma)
 No sign of cyanosis
(There are can eliminate diagnosa of heart disease)
DIAGNOSIS:ASTHMA(The kind of COPD)

ANSWER QUESTION PAPER

1.What is the most likely cause of this patient’s dyspnea?

Answer:Asthma(The kind of COPD)
2.What acute treatment’s are most apropiate at this time?
Answer:Nebulizer(The medicine is Salbutamol)
3.What Intervention would be most helpful to reduce the risk of future
exacerbation of this condition?
Answer:Smoking
Answer: Cessation,Bronchodilators,Glucocorticoids ,Management of
a1AT Deficiency,Oxygen,Prophylaxis,Rehabilitation