Medical Exam Q&A

A 70 year old man is admitted for treatment of an infective exacerbation of COPD
which has been diagnosed as chronic bronchitis. He presented with a 3 day history of
malaise, increasing shortness of breath and a cough which is productive of
purulent sputum and has been admitted several times previously with a similar
problem. He has a history of peptic ulcer disease, hypertension and atrial fibrillation.
His medications include Nuseals aspirin, becotide, salbutamol, warfarin,
ramipril and domiciliary oxygen (home oxygen). He is married, is a social drinker and
an ex-heavy smoker.
On examination, he appears alert but is mildly cyanotic. His blood pressure is 160/100
mmHg, his pulse is 120 beats per min. and is irregularly irregular and his respiration
is laboured with a respiratory rate of 18/min. His temperature is 38C.
He has truncal obesity, a round plethoric face and exhibits numerous abdominal striae
and a buffalo hump.
Examination of the chest reveals generalised wheeze with a general decrease in air
entry. There is an area of dullness to percussion in the left lower lobe. Auscultation of
the heart is unremarkable but a parasternal heave is felt. A liver edge is palpable and
his JVP is raised. Arterial blood gas analysis reveals hypoxia and hypercapnia. Full
blood count shows a raised white cell count and an increased red cell mass. His INR
is 5. Chest X-ray was performed. Sputum is sent to the microbiology laboratory and
parenteral therapy is commenced.
a) Describe the pathologic changes in chronic bronchitis.

-hypertrophy of bronchia mucous gland
-increased no of goblet cells
Hyepesrsectretion of mucus
Bronchial squamous metaplasia and dysplasia
In short: hypersecretion of mucus in response to chronic injury of the lung
b) Define the terms in bold type.
COPD- Chronic Obstructive Pulmonary Disease i.e. a disease characterized by
irreversible. airflow obstruction that is usually progressive. It is associated with
abnormal inflammatory response to noxious particles/gases
Purulent- Containing the products of pus
Peptic ulcer disease- ulcers of the distal stomach caused by gastric secretions and
impaired mucosal defences
c) Give an explanation for the sentence which is underlined.
He has truncal obesity, a round plethoric face and exhibits numerous abdominal
striae and a buffalo hump.
There is an abnormal fat deposition on his trunks, and his face appears swollen and
round he has a hump on his back. These are all classical presentation of cushing
syndrome.
d) Describe the pathologic changes seen on chest X-ray.
There will be area of opacity on the left lower lobe
e) Give 2 reasons why he is tachycardic.

High blood pressure
Arrythmia
f) What type of respiratory failure does he have? Give your reasons.
Type II
-because he has a reduced oxygen saturation but increased carbon dioxide saturation
I dont know what else!
Lobar Pneumonia.
Production of purulent sputum is indicative of infection.
Dullness upon percussion on a specific area of lung (lower lobe of left lung) is
evidence of consolidation
A high white blood cell count is indicative of inflammation
g) What cardiac complication of his COPD does this man have evidence of?
Right Heart Failure (cor pulmonale)
h) Delineate the evidence and explain the pathogenesis of the complication.
Lung disease makes it hard for blood to flow to lung from right ventricle. This causes
pulmonary hypertension and hence increases right ventricular pressure causing right
ventricular hypertrophy leading to right sided heart failure.
i)How would the sputum be processed in the microbiology laboratory?
Treat with digesting agent. This liquefies the sputum and
releases any bacteria trapped in the mucus. Specimen is
then centrifuged and the deposit is processed in two ways.
1)GRAM
Note predominant
organisms and number
of pus and/ or epithelial
cells present
2)CULTURE on
Blood agar (incubate O2)
Chocolate agar (incubate CO2)
18-24 hours incubation
Identify any organisms grown
Set up antibiotic susceptibility test on any significant growth (e.g. S. pneumoniae or
H. influenzae or Moraxella catarrhalis)
During admission, his condition improves and after several days, he is switched to
oral antibiotics. However before
discharge he suffers an episode of haematemesis.
j) What is haematemesis?
Vommitting of blood
k) What are his risk factors for haematemesis?

Peptic ulcer disease
COPD
Alcohol history
Aspirin intake

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A 70 year old man is admitted for treatment of an infective exacerbation of COPD

a) Describe the pathologic changes in chronic bronchitis.

e) Give 2 reasons why he is tachycardic.

k) What are his risk factors for haematemesis?

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