І.

INITIAL QUESTIONS

1. Baseline investigations for patients with chronic cough.

2. Clinical picture of COPD, GOLD I, group B
3. Treatment of moderate persistent bronchial asthma.

II. CASE REPORT

A 65 year old Cuban male comes to the ED because of shortness of breath.

He notes that over the last 2-3 years he has had gradual worsening of his ability to
exert himself without feeling out of breath, and it has been acutely worse for the
past week, including a worsening productive cough. On questioning, he reveals
that he coughs almost every morning as well, and this has been going on for even
longer, perhaps 4-5 years. The cough is now productive of yellowish-brownish
sputum. He denies chest pain, fevers, chills or night sweats. He has no history of
lower extremity edema. The rest of his review of systems is negative.
Other than an appendectomy when he was in his 20’s, the patient denies any
significant past medical history. He denies taking any medications, but does state
that a year ago he went to a walk-in clinic for cough and got some kind of inhaler,
which he used over the course of a month or two until it was gone. He lives in an
apartment with his wife, and has smoked a pack of cigarettes a day for 40 years.
On exam, his BP is 144/88 mmHg, HR is 98, respiratory rate is 28 breaths
per minute. His temp is 97.6. Oxygen saturation is documented as 93% on 4 L.
You find him sitting up in the ED bed, leaning forward. He appears uncomfortable
with labored breathing and his lips are bluish. There is no cervical
lymphadenopathy, JVD or carotid bruits. Chest exam shows mild intercostal
retractions seen around the anterolateral costal margins. Wheezes and rhonchi are
present bilaterally, without crackles. Heart exam is unremarkable, though the heart
sounds are distant. Lower extremities show no cyanosis, clubbing or edema.
 What is the most likely diagnosis?
 How would you confirm the diagnosis?
 Prescribe further investigations.
 Prescribe initial treatment.
III. INTERPRET THE RESULT OF THE INVESTIGATION
Result Normal range
PEFR (l/min) 450 383-518
FEV1 (l) 2.75 2.34-3.16
FVC (l) 4.05 3.45-4.66
FEV1/FVC (%) 69 58-79

A 30-year-old male was admitted with fever, cough with haemoptysis, and
dyspnea. A few red blood cells but no microorganisms were noted on a sputum
gram stain.
What does the lung function test show?

ІV. PRESCRIPTONS

1. Prescribe formoterol/budesonide for patient with mild persistent bronchial

asthma.
2. Prescribe salmeterol/fluticasone for patient with COPD GOLD IV, group C.