Pulmonary Case #1
Steven Stites M.D. (c) 1997
edited by Michael Gordon,
- A 58-year-old smoke went to his
- 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
- 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
- He saw his physician
- His only current
medication was aspirin, which he took one
of a day.
- He denied chest pain,
nausea and vomiting, diarrhea or
- 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
- 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
- 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?