Case history
Case history
A 39-year-old man presents for the third time in 2 years (to different physicians each time) for evaluation of an intermittent productive cough and increasing dyspnea on exertion. He has a 15 pack-year smoking history, reports thick, yellow phlegm at times, and describes having trouble keeping up when playing with his children. His medical history reveals mild intermittent asthma controlled with an albuterol inhaler. His symptoms have persisted despite stopping smoking, and his asthma exacerbations have increased in frequency, with some attacks being unresponsive to albuterol. Physical exam reveals a generally healthy-looking male. During the exam he experiences coughing with subsequent wheezing on auscultation and a long expiratory phase. Cardiac exam is normal. Spirometry demonstrates an FEV1 of 40% of his predicted value.
Other presentations
Patients with pulmonary manifestations may also present with fatigue, chest tightness, and/or exercise intolerance. Patients with hepatic manifestations may present with jaundice, scleral icterus, abnormal liver function tests, fatigue, asterixis, hepatic encephalopathy, bleeding/bruising, and/or esophageal varices. Hepatocellular carcinoma presents with worsening liver function, abnormal liver imaging, rising alpha-fetoprotein levels detected in blood serum, and sometimes pain.
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