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Respiratory: breathless and coughing

The house officer asks some key questions and discovers that Mr Snow is producing a rusty coloured sputum without blood and has no chest pain. In his past medical history she finds that he has treated hypertension, high cholesterol, and has had asthma when he was a child. He has no known drug allergies. He has not lost any weight recently. He has been to the hospital twice before with “pneumonia”. What is the most likely diagnosis?

How is the underlying condition best described?

What other risk factors are relevant for this condition?

  • Significant day to day variation
  • Night time wheeze and/or breathlessness
  • <35 years old
  • Relatively constant from day to day
  • Persistent and progressive breathlessness
  • >35 years old
  • Variable breathlessness
  • Chronic productive cough
  • Smoker

  • Chronic cough
  • Peripheral vasodilation
  • Decreased lung elastic recoil
  • Progressive destruction of alveolar septa
  • Barrel chest
  • Normoxic at rest
  • CO2 retention
  • Chronic mucous hypersecretion
  • “Blue bloater”
  • Bounding pulse
  • “Pink puffer”

Mr Snow will need treatment in the form of salbutamol, ipatropium bromide, amoxicillin, and high-flow oxygen. With which of these treatments should the house officer be most concerned about prescribing?

He normally takes nifedipine, bisoprolol and ramipril for his hypertension and takes simvastatin for high cholesterol. Should the junior doctor consider stopping any of these medications for the time being?

After starting treatment, Mr Snow immediately feels that he can breathe better. He reveals that he thinks everything is due to his smoking, but feels that it is pointless to quit now as “the damage has already been done”. What should the house officer advice?

With treatment for this acute exacerbation Mr Snow improves significantly. Feeling better he takes on quitting smoking, and through the GP referring him to smoking cessation programmes he is able to quit smoking and go to the pub without struggling!
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Basics of COPD.


Time-volume graph showing normal and obstructive patterns. Obstructive pattern is shown when FEV1 divided by FVC is less than 70%. © 2010 Christie Choo.

CTCT scan of emphysema. There are large bullae shown. This indicates severe emphysema. © 2013 Simon Freilich.

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