Pulmonary Case #1

authored by Steven Stites M.D. (c) 1997

edited by Michael Gordon, Ph.D.

  • A 58-year-old smoke went to his physician.
    • He had a chief complaint of shortness of breath, mild sharp substernal chest pain and a cough productive of green sputum.
    • He had developed over the last several months, increasing dyspnea on exertion. Whereas before he had been able to mow his yard without stopping, he now had to rest several times.
    • He also complained of an increased rate of decline over the last several weeks which coincided with symptoms of post nasal drainage, a sore throat and feeling of fullness in his sinuses.
    • He also admitted to a "smoker's cough", which was prevalent most mornings and produced white to tan sputum. This cough had been present for several years.
    • His past medical history was notable for tobacco use up to two packs per day for 30 years.
    • He had been told that he might have coronary artery disease and he had been followed for borderline hypertension.
    • He saw his physician infrequently.
    • His only current medication was aspirin, which he took one of a day.
    • He denied chest pain, nausea and vomiting, diarrhea or weakness.

  • Physical exam found a normotensive man with a blood pressure of 120/78 mm Hg.
  • His pulse was regular at 69 and his respiratory rate was 20.
  • His posterior pharynx had mild erythma and there was sinus tenderness on his right frontal sinus.
  • Neck was supple with no adenopathy.
  • Lung exam found diffuse bilateral mild wheezing with basilar rhonchi. Forced expiration resulted in coughing.
  • Heart exam found a regular rate and rhythm with no murmur or rub.
  • Abdomen and musculoskeletal exam were unremarkable; there was no cyanosis or edema.
  • Chest x-ray was consistent with mild chronic obstructive lung disease.
  • A CBC had a white count of 8.6 with 80% Segs.
  • Electrolytes and renal function were within normal limits.
  • His hemoglobin was 14.
  • Pulmonary function tests demonstrated reduction in his forced expiratory volume over 1 second to 70% of normal. His FEV1/FEV ratio, a marker of obstructive lung disease, was reduced to 62%. The patient was started on a course of Ampicillin for acute bronchitis.

What is the most probable diagnosis and pathophysiology in this patient given his history as described?