History and Physical Exam

A 74-year-old retired shipyard laborer with a 45+ pack-years (pack-a-day for 45 years) smoking history and previous work in sandblasting and fiberglass presented with increasing dyspnea and peripheral edema.

On physical examination, he was a thin, cyanotic man in moderate pulmonary distress who was afebrile with a heart rate of 90, respiratory rate of 28, and blood pressure of 125/90. His chest showed increased A-P diameter and the breath sounds were faint with a prolonged expiration. The liver edge was 3 cm below the right costal margin. There was digital clubbing with cyanosis and marked peripheral edema.

Questions:

  1. What clinical disorders do the smoking and work history suggest?
  2. Does the physical exam support any of those diagnoses?
  3. What is likely to be the patient's immediate problem?
Fifteen months prior to this presentation, the patient had undergone pulmonary function testing with the following results:

Blood gases: 

            Room Air          100% oxygen
pO2            43 mm Hg           452 mm Hg
pCO2           22                  34
pH           7.51                7.38
Pulmonary function tests (values shown as % of expected value): 
FEV1                   61%
Vital Capacity         73%
FEV1/VC              0.61  (normally >0.72)
Residual volume       175%
Total lung capacity   105%
Diffusion Cap. CO      13%
Ultrasound revealed right ventricular hypertrophy.

Questions:

  1. Does the patient's hypoxemia correct with oxygen? What does this mean?
  2. What happens to the patient's acid-bases status when he is placed on oxygen?
  3. Are the pulmonary function tests consistent with the impressions given by the history and physical? How so?
Lab studies obtained at the current presentation showed: 
Hematocrit       48%
WBC            7400 /ul
Bicarbonate      21 meq/l

Arterial Blood Gases (100% oxygen)
   pO2       413
   pCO2       40
   pH       7.37
A pulmonary arterial line showed right ventricular pressures of 100/25

Question:

  1. Are these results comparable with the previous studies?
The patient was admitted to the hospital.