CLINICAL CASE

FOR: VIMOS MILTON

ANDREA CASTILLO
KAREN BARROS
STEFANY ARTEAGA

OBJECTIVES:
GENERAL PURPOSE

Analyze clinical case a reference to CHRONIC BRONCHITIS

SPECIFIC OBJECTIVES

Perform a detailed history following basic structure : personal data, present illness , review of
systems , general and regional physical exam.
Determine affiliation data by risk factors that may be related to the pathology under study

PERSONAL DETAILS
Name: NN
Age: 52 years old
Sex: Male
Marital status: Married
Instruction: School

Profession: Farmer
Religion: Catholic
Place of birth: Bolivar
Occasional residences: Riobamba
Habitual residence: Bolivar

PRESENTING COMPLAINT
FEVER
COUGH
EXPECTORATION

PRESENT ILLNESS
Chronic smoker patient begins three days ago with fever,
accompanied by cough with expectoration of mucopurulent
appearance. Symptoms have been increasing and today the
patient is cyanotic and sleepy. The family reports that he
doesnt sleep at night and during the day he complains of
headaches and stay asleep easily in the chair, also is very
irritable and sometimes disoriented and has a strange
behavior.

PAST MEDICAL HISTORY

Chronic bronchitis.
Regular smoker more than 20 cigarettes / day until recently
( now no longer smoke) .

Physical exploration:
Conscious patient, responding to simple verbal
commands but very sleepy and unreactive.
Isochoric and reactive pupils.
Move all members well; has good muscle tone and
hasnt no signs of neurological deficit, but has a
particularly valuable tremor in the upper limbs.
Is an obese patient, have congestive appearance and
severe cyanosis of skin and mucous membranes.

Physical exploration:
Auscultation pulmonary: It shows severe diffuse expiratory
wheezing .
Auscultation heart: Normal cardiac auscultation.
Abdomen and limbs without pathological interest.

Physical exploration:
Vital Signs :
Blood Pressure: 140/90
Heart Rate : 87 contractions/ minute
Respiration: 16 breaths/ minute
Temperature: 36,8

Further exploration
The basic analysis of urgency practiced displays the
following data: Hb 17.4 g / dL , Hto 55 % , Leukocyte
12,300. Fla : C / 6 , S / 81 , L / 9 , F / 4

Room air arterial blood gases :

pH7,29 ; PCO276 ; PO243 ; HCO3 37

Further exploration
The x- ray shows enlarged and deformed hilios, image
compatible with a picture of chronic bronchitis. No images
of pulmonary condensation, so that is discarded picture
compatible with pneumonia.

DIAGNOSIS
Clinical history and chest radiography are typical of
CHRONIC BRONCHITIS
The analytical sample polyglobulia
RESPIRATORY FAILURE
Leukocytosis that indicates possible
INFECTION

CHRONIC
RESPIRATORY

TREATMENT:
Treatment should consider:
a) treat the underlying disease :
No Smoking
Bronchodilators
If there is fever : antibiotics
b ) Treatment : O2CFiO2 low ( 0.24 mask endonasal or glasses)
c ) Treatment of the cause of decompensation ( respiratory infection) :
antibiotics , such as amoxicillin -clavulanate or quinolones.