CASE STUDY 24 - Miguel Perez - Respiratory

Miguel Perez is a 65-year-old farmer who has managed his own large farm for many years. He has smoked two packs of cigarettes a day for 35 years. During the last few years Mr. Perez has experienced slight shortness of breath and a mild cough with activity. He also coughs after arising each morning. Mr. Perez noticed recently that he has difficulty climbing the stairs at home because of fatigue and he must stop at intervals to catch his breath. He has also noticed being short of breath even sometimes at rest. He has lost 10 pounds in the last 2 months. He has been sleeping sitting up or propped by several pillows.
On admission to the emergency room, he is a thin, frail-looking man in acute respiratory distress. He is restless and breathing rapidly. He is sitting on the side of the bed leaning on the bedside table. His heart rate is 120, respirations are 30, and blood pressure is 140/80. Auscultation of the lungs reveals decreased breath sounds with expiratory wheezes. His chest has an increased anteroposterior diameter, giving it a barrel shape, and he is using accessory muscles to breathe. Arterial blood gas results reveal a decreased PO2, an increased PCO2, a low pH, and a high bicarbonate level. Pulmonary function tests reveal decreased tidal volume, decreased vital capacity, increased total lung capacity, and a prolonged forced expiratory volume. A chest x-ray reveals a flat low diaphragm, hyperinflation of the lungs, clear lung fields, and no evidence of cardiac enlargement. He is started on 2 liters of oxygen by nasal cannula in the emergency room.

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