58y/o Malay man with Chronic Obstructive Pulmonary Disease (COPD) presented with breathlessness, rhinitis, sore throat and cough. He has no history of hypertension/diabetes mellitus type II
On MDI salbutamol,MDI budesonide, MDI Ipratropium bromide; claims compliant
Control: Poor. Frequent use of salbutamol (almost everyday) and frequent waking up at night (3-4 times/week) due to breathlessness. No reduction in effort tolerance. Aggaravted by: smoke from roti canai making. relieved by medications.
No failure symptoms such as orthopnea, leg swelling.
On admission he was alert, conscious and but tachypenic with the use of acessory muscles. he not able to speak in full sentences.
BP:117/72 mmHg
Pulse: 95 beats/min regular rhythm strong volume
Temperature:37.5
SpO2: 94% on room air
Respiratory rate: 22 breaths/min
Random blood gluocose: 6.5
Cardiovascular examination was normal.
Respiratory examination revealed prolonged expiration with generalized rhonchi (both inspiratory and expiratory) on both lung fields on the lung fields. (More prominent on the right side.
The Abdomen and Neurological examinations were normal.
Ix:
FBC:Hb:12g/dl;TWC: 7.5;Plt:233-->normal parameters
ABG: no signs of acidosis/alkalosis
RP: low pottasium (2.98) otherwise normal
LIpid profile: HDL low (1.2) otherwise other parameters are within normal range
ECG: sinus rhythm.no ischemic changes. no evidence of right ventricular hypertropy/right atrial hyperthropy.
Chest X-ray: hyperinflated chest;tubular heart. no evidence of cardiomegaly/pneumatic changes.
Impression: Acute exacerbation of COPD secondary to URTI
Plan:
1. IV hydrocortisone 200mg stat
2. Nebulise; Atroven,Ventolin, Normal saline: 1:1:2
3. supply oxygen via nasal prong (3liters/min) and prop up patient
4. MDI salbutamol PRN
5. assess peak expiratory flow
6. T.slow K 1/1 TDS
Day 2
On admission he was alert, conscious and tachypenic with the use of acessory muscles. he is able to speak in full complete sentences however there were ocassional stuttering
BP:114/70 mmHg
Pulse: 75 beats/min regular rhythm strong volume
Temperature:37.5
SpO2: 96% on room air
Respiratory rate: 20 breaths/min
Fasting blood gluocose: 5.0
Cardiovascular examination was normal.
Respiratory examination revealed prolonged expiration with generalized rhonchi (both
inspiratory and expiratory) on both lung fields on the lung fields. (More prominent on the
right side. However, the rhonchi has reduced in intensity as compared to yesterday.
The Abdomen and Neurological examinations were normal.
Impression: Acute exacerbation of COPD secondary to URTI
Plan:
1. IV hydrocortisone 100mg QID 1/7 then change to T.Prednisolone 40mg OD 5/7
2. Nebulise; Atroven,Ventolin, Normal saline: 1:1:2 4 hourly
*should have repeated RP in view of salbutamol administration*
Day 3
On examination he was alert and comfortable. he is able to speak in full complete sentences without stuttering.
BP:118/72 mmHg
Pulse: 70 beats/min regular rhythm strong volume
Temperature:37.5
SpO2: 96% on room air
Respiratory rate: 18 breaths/min
Fasting blood gluocose: 5.3
Peak expiratory flow meter: 250L/min (prior to bronchodilators)
Peak expiratory flow meter: ___ L/min (after bronchodilators)
Cardiovascular examination was normal.
Respiratory examination revealed prolonged expiration with generalized rhonchi (both
inspiratory and expiratory) on both lung fields on the lung fields. (More prominent on the
right side. However, the rhonchi has reduced in intensity as compared to yesterday.
The Abdomen and Neurological examinations were normal.
Impression: Acute exacerbation of COPD secondary to URTI
Plan:
1. stop IV hydrocortisone and change to T.Prednisolone 40mg OD 5/7
2. Nebulise; Atroven,Ventolin, Normal saline: 1:1:2 4 hourly
3. Lung function test as outpatient
4. MDI Berodual BD 2puffs
5.Start on Tablet Bisolvon 8mg tds
6. Start T.Neulin SR 250mg BD (theophyline)
*should have repeated RP in view of salbutamol administration*
