Case Year Comes Explained for Students (Easy Guide)
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Original Question
Case 3 A 58 year old man comes to your office because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining; as a result he spends the night sitting up in a chair trying to sleep. He reports a cough with production of yellowish-brown sputum every morning throughout the year. He denies chest pain, fever, chills or lower extremity edema. He has smoked about 2 packs of cigarettes per day since age 15. He does not drink alcohol. A few months ago, he went to an urgent care clinic for evaluation of his symptoms, & he received prescriptions for some inhalers, but he doesn’t remember the names. He was also told to find a PCP for further evaluation. On physical examination, his BP is 135/85, heart rate is 96, RR 28, T97.6. He is sitting in a chair, leaning forward, with his arms braced on his knees. He appears uncomfortable, with labored respirations & cyanotic lips. He is using accessory muscles of respiration. Chest examination reveals wheezes and rhonchi bilaterally, but no crackles are noted. The anteroposterior diameter of the chest wall appears increased, and he has inward movement of the lower rib cage with inspiration. CV exam reveals distant heart sound but regular rate & rhythm and his jugular venous pressure is normal. His extremities show no cyanosis, edema or clubbing. He is diagnosed with an acute exacerbation of COPD.
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