45-year-old woman presents with chief complaint of 3-day duration of shortness of breath, cough with thick green sputum production, and fevers. Patient has history of COPD with chronic cough but states the cough has gotten much worse and is interfering with her sleep. Sputum is thicker and harder for her to expectorate. CXR reveals flattened diaphragm and increased AP diameter. Auscultation demonstrates hyper resonance and coarse rales and rhonchi throughout all lung fields.

This case presents a 45-year-old woman with a chief complaint of shortness of breath, cough with thick green sputum production, and fevers lasting for three days. The patient has a history of chronic obstructive pulmonary disease (COPD) with a chronic cough, but she reports that the cough has become significantly worse and is interfering with her sleep. Additionally, she mentions that her sputum has become thicker and is more difficult for her to expectorate. A chest X-ray (CXR) reveals a flattened diaphragm and increased anterior-posterior (AP) diameter. Pulmonary auscultation reveals hyper resonance and coarse rales and rhonchi throughout all lung fields.

Given the patient’s symptoms and medical history, it is important to consider possible exacerbation of COPD, which is a common respiratory condition characterized by chronic bronchitis and emphysema. Exacerbations are acute worsening of symptoms beyond normal day-to-day variations. These exacerbations can be triggered by various factors, such as infections, air pollution, or exposure to irritants.

Shortness of breath is a cardinal symptom of COPD exacerbation and is often associated with increased work of breathing due to decreased lung function and increased airway resistance. The patient’s worsening cough, with the production of thick green sputum, suggests an exacerbation with increased sputum production and potentially bacterial infection. Fever is another common symptom associated with exacerbations, typically indicative of an underlying infection.

The findings on the CXR are consistent with the known effects of COPD on lung structure. The flattened diaphragm and increased AP diameter are both signs of hyperinflation, which occurs due to air trapping in the lungs. In COPD, there is often destruction of the alveolar walls and loss of elastic recoil, leading to increased residual volume and decreased expiratory flow rates.

The pulmonary auscultation findings of hyper resonance, coarse rales, and rhonchi throughout all lung fields can be attributed to the underlying bronchial obstruction and air trapping. Hyper resonance refers to increased resonance on percussion due to increased air volume in the lungs. Coarse rales and rhonchi indicate the presence of mucus and secretions in the large and small airways, respectively.

Based on the patient’s presentation and physical examination findings, a possible diagnosis of acute exacerbation of COPD with associated respiratory infection can be considered. This is a common clinical scenario in patients with COPD, especially in those with a history of chronic cough and increased sputum production. The worsening symptoms, such as increased shortness of breath, difficulty expectorating sputum, and fever, further suggest an infectious etiology.

The next step in management would entail confirming the diagnosis and determining the severity of exacerbation. This can be achieved through ancillary tests, such as sputum culture and complete blood count (CBC) to identify the causative organism and measure markers of inflammation, respectively. Additionally, arterial blood gas (ABG) analysis can help evaluate the degree of respiratory impairment and guide oxygen therapy.

Treatment of acute exacerbations of COPD typically involves a combination of bronchodilators, corticosteroids, and antibiotics. Bronchodilators, such as short-acting beta-agonists and anticholinergic agents, provide relief by relaxing the airway smooth muscles and improving airflow. Corticosteroids, such as prednisone, are used to reduce airway inflammation. Antibiotics are prescribed in cases where there is suspicion of bacterial infection. The choice of antibiotic should be guided by local resistance patterns and the presence of risk factors for multidrug-resistant organisms.

In conclusion, this case describes a 45-year-old woman with a history of COPD who presents with worsening shortness of breath, increased sputum production, and fever. The clinical presentation, along with findings on CXR and pulmonary auscultation, suggests an acute exacerbation of COPD, possibly associated with a respiratory infection. Confirmatory tests and appropriate management strategies, including bronchodilators, corticosteroids, and antibiotics, should be implemented to improve the patient’s symptoms and prevent further deterioration.

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