tailieunhanh - Clinical Problems in General Medicine and Surgery_2

First published in 1992, Clinical Problems in General Medicine and Surgery was principally written for senior medical students and interns, about to or already experiencing the real world of medical practice. It was a departure from 'traditional' medical texts in that the book dealt with the real problems of clinical medicine through scenarios encountered in the emergency department, on the wards and in outpatient clinics. How to manage the comatose patient? How to manage the young man with chest pain? What to do with the rowdy, confused patient on the ward, or the jaundiced patient in the clinic?. | A 62-year-old man with breathlessness and yellow sputum You are working in the emergency department one winter evening. A 62-year-old man is brought in by ambulance acutely short of breath. The history is obtained mainly from the patient s wife. She claims he has had difficulty with his breathing for about 4 years and can now only walk at a slow pace for 50 metres and then has to stop due to breathlessness. He has had a smoker s cough for as long as she can remember and has produced phlegm on most days for many years. He has had a number of chest infections this winter despite repeated courses of antibiotics and as a result the local doctor placed him on theophylline tablets. On this occasion the man has been unwell for 1 week. During this time he has been producing thick yellow-green sputum which he has found difficult to cough up. He has been sitting up at night in a chair and has been unable to do anything due to his breathlessness and extreme fatigue. He has become nauseated and is eating very little. He has not had a tem perature or shivers or chest pain. He has not noticed any blood in his sputum and he has not had ankle swelling. The patient has been on antibiotic tablets for 5 days but there has been no improvement. The man suffered a myocardial infarction at the age of 60 and underwent a right femoropopliteal bypass 4 years ago. He has not had angina since his heart attack and is not on any cardiac medication. He does not have hypertension or diabetes mellitus. He had experienced pain in the left calf on walking up until the last 6 months when he has been more troubled by breathlessness. He is on a salbutamol puffer 2 puffs 4 hourly theophylline slow-release tablets 300 mg bd and amoxicillin 250 mg 3 times a day. He currently smokes 5 cigarettes a day but until 3 months ago smoked 30-60 a day and had done so since the age of 17. He claims he finds benefit from the smoking as it seems to aid the clearing of his sputum. QI What is the likely diagnosis What .