Case Presentation: Chronic Obstructive Pulmonary Disease (COPD)

Identification Data

Name: Mr. Vijayan Menon

Age/Sex: 62 years/Male

Education: High School

Occupation: Retired Auto-rickshaw Driver

Address: Fort Kochi, Kerala

Date of admission: [Current Date]

Date of examination: [Current Date]

Informant: Patient (reliable)

Presenting Complaints

• Chronic cough with sputum production for more than 10 years.

• Progressive shortness of breath for the past 5 years, worsening over the last 6 months.

• Frequent exacerbations of cough and breathlessness, particularly during the winter months * 5 years

History of Present Illness :

Mr. Vijayan Menon, a 62-year-old retired auto-rickshaw driver residing in Fort Kochi, reports a long-standing and progressive history of respiratory symptoms, which he attributes to his extensive smoking habit.

His symptoms began insidiously over 10 years ago with a chronic cough. Initially, the cough was sporadic, but over time, it became persistent, occurring almost daily throughout the day and night. He describes the cough as productive, typically bringing up whitish to yellowish sputum, which he estimates to be about half a cup per day. The sputum consistency varies; it is often tenacious and difficult to expectorate. He notes that the cough is particularly troublesome in the mornings upon waking, when he experiences prolonged coughing fits to clear his airways. He denies any foul smell, blood, or frothy nature to the sputum.

Approximately 5 years ago, he started experiencing shortness of breath (dyspnea). This initially manifested as breathlessness only on moderate to heavy exertion, such as climbing two flights of stairs or brisk walking (corresponding to an MMRC Grade I). However, over the subsequent years, his dyspnea has gradually worsened, reaching a point where, for the past 6 months, he feels breathless even with minimal activities like walking across a room, dressing, or showering (now equivalent to MMRC Grade III-IV). He often has to pause multiple times while walking short distances. He denies any orthopnea (difficulty breathing while lying flat) or paroxysmal nocturnal dyspnea (sudden attacks of breathlessness at night).

He reports experiencing frequent chest infections with exacerbations of his respiratory symptoms for the past 5 years. These exacerbations are characterized by a marked increase in his cough and sputum volume, with the sputum often becoming more purulent (yellowish-greenish). Concurrently, his breathlessness significantly worsens, sometimes forcing him to sit upright to breathe (tripod position). These episodes occur multiple times per year, particularly during the winter months. He typically manages these exacerbations with oral antibiotics and nebulized bronchodilators prescribed by his local physician, which provide temporary relief. He denies any associated fever, chills, night sweats, or significant unintentional weight loss during these exacerbations. He mentions occasional wheezing that accompanies these severe bouts of breathlessness. He denies any chest pain, palpitations, or swelling of the ankles.

Past History

• No known history of hypertension, diabetes mellitus, or tuberculosis.

• No history of any major surgeries or hospitalizations other than for previous COPD exacerbations.

Family History

• No known family history of COPD or other significant respiratory illnesses.

Personal History

• Smoking: A heavy smoker for 40 years, averaging 20-25 bidis/cigarettes per day. He quit smoking 3 years ago upon the advice of his local physician.

• Alcohol: Occasional social drinker.

• Diet: Mixed diet, predominantly rice and fish, typical of the region.

Socioeconomic History :

• Belongs to a lower middle-class family.

• Lives with his wife in a small house near the coast, with moderate ventilation.

• His occupation as an auto-rickshaw driver likely involved significant exposure to vehicular pollution.

General Examination

• Patient is conscious, oriented, and cooperative.

• Thin built, appears in moderate respiratory distress at rest.

• Mild central cyanosis noted.

• No pallor, icterus, clubbing, or lymphadenopathy.

• Pursed-lip breathing observed.

• Use of accessory muscles of respiration noted.

• Barrel-shaped chest observed.

Vitals:

• PR: 108/min, regular, normal volume and character.

• BP: 135/85 mmHg in right upper limb in sitting position.

• RR: 26/min, labored, predominantly thoracic.

• Temp: 98.8°F (afebrile).

• SpO₂: 88% (room air).

Respiratory System Examination Inspection

• Shape of chest: Barrel-shaped.

• Trachea appears central

• Apical impulse not visible

• Respiratory movements are shallow and rapid.

• Use of accessory muscles of respiration (sternocleidomastoid, scalene) visible.

• No scars or deformities.

Palpation

• Trachea is central.

• Inspection findings confirmed by palpation

• Apex beat palpable in the epigastric region (suggestive of hyperinflated lungs).

• Chest expansion is reduced bilaterally in upper anterior, upper posterior, lower anterior, lower posterior and apical areas

• Vocal fremitus equal bilaterally

Percussion

• Supraclavicular: Hyper-resonant bilaterally.

• Clavicular: Hyper-resonant bilaterally.

• Infraclavicular: Hyper-resonant bilaterally.

• Mammary: Hyper-resonant bilaterally.

• Axillary: Hyper-resonant bilaterally.

• Infra-axillary: Hyper-resonant bilaterally.

• Suprascapular: Hyper-resonant bilaterally.

• Interscapular: Hyper-resonant bilaterally.

• Infrascapular: Hyper-resonant bilaterally.

Additional Percussion Findings:

• Diaphragmatic excursion: Reduced bilaterally.

• Cardiac dullness: Reduced.

• Liver dullness: Displaced downwards (in 7th RICS in MCL)

Auscultation

• Breath sounds are globally diminished, with a prolonged expiratory phase heard bilaterally.

• Scattered wheezes and crackles heard bilaterally, more prominent during expiration.

• Vocal resonance equal bilaterally, diminished.

Cardiovascular System Examination

• Heart sounds are distant.

• S1 and S2 heard, no murmurs appreciated.

Other Systemic Examination

• Abdomen soft, non-tender, no organomegaly.

• No peripheral edema.

• Neurological examination unremarkable.

Summary

Mr. Vijayan Menon, a 62-year-old retired auto-rickshaw driver and former heavy smoker from Fort Kochi, presents with a long history of chronic productive cough and progressive shortness of breath, significantly worsening over the past 6 months with frequent exacerbations. Clinical examination reveals signs of hyperinflation (barrel chest, low diaphragm, displaced cardiac dullness), reduced breath sounds with prolonged expiration and scattered adventitious sounds, and clinical signs of hypoxemia.

The clinical presentation is highly suggestive of Chronic Obstructive Pulmonary Disease (COPD), likely with features of both chronic bronchitis (due to the chronic productive cough) and emphysema (due to the hyperinflation and reduced breath sounds). His significant smoking history and occupational exposure to pollutants are strong risk factors.