Description
The patient was an elderly man who was propped up in bed
and breathless. He was of average height but he was thin.
On examination of his head the only abnormality that could
be detected was that he had flaring of the alae nasi.
His hands showed clubbing of the fingers; there was no
other abnormality. Pulse rate was 100 beats per minute regular; there was no
flapping tremor.
His neck was thin, the JVP was not elevated, the trachea
was in the midline the cricothyroid distance was just about a finger breadth.
On examination of his chest there was pectum excavatum, the
chest was symmetrical and respiratory movements were equal on the two sides.
The respiratory rate was 24 per minute. The apex beat was
difficult to palpate. Respiratory movements were equal when assessed by
palpation. Vocal fremitus was equal on the two sides. The percussion note was
resonant and equal on the two sides; liver dullness and cardiac dullness were
reduced. Breath sounds were vesicular; there were fine late inspiratory
crepitations at both bases. There was no change in the crepitations when the
patient was asked to cough. There were no rhonchi.
Vocal resonance was normal and equal on the two sides.
There was a salbutamol inhaler on the bedside cabinet.
Analysis
♥
The patient was breathless at rest. Dyspnoea may be due to a
number of causes (Page 245)
ª
The patient was thin. This would indicate chronic lung disease or
advanced malignancy (Page 248)
¨
There are many causes of clubbing in relation to respiratory
disease. (Page 254) The fact that the
patient is dyspnoeic at rest makes it more likely to be diffuse lung disease
rather than a localised lung disease
§
The decreased cricothyroid distance suggests the patient has
obstructive pulmonary disease (Page 257)
No patient with an acute attack of asthma will be brought into an exam as a case
hence the most likely cause is emphysema
♥
As the chest was symmetrical and respiratory movements were equal
on the two sides, localised lung disease is unlikely. We already know the
patient has emphysema but the cause of clubbing is not known. Brochiectasis and
fibrosing alveolitis would affect both lungs and these are the most likely
causes.
ª
We have not seen a sputum pot by the bedside and the patient has
not coughed during the examination so the likely diagnosis is fibrosing
alveolitis.
¨
The patient was tachypnoeic (Page 260).
This fits in with our presumptive diagnosis of emphysema.
§
The finding of fine late inspiratory crepitations
(Page 264, 265) fits in with the diagnosis of
fibrosing alveolitis.
Diagnosis
♥
Chronic Obstructive Pulmonary Disease (Emphysema)
ª
Fibrosing Alveolitis
