Acute Exacerbation
of Chronic
Pulmonary Airway
Disease
Patient’s profile
Name : Musa bin Hasan
Gender : male
Age : 52 years old
Race : Malay
Nationality : Malaysian
Occupation : settler
Address : Tasik Bera
Marital status : married
Date of admission : 16 June 2009
Date of clerking : 18 June 2009
Date of discharge : 22 June 2009
Source of clerking : patient
Presenting complaint
Shortness of breath and wheezing for 2 days associated with cough and runny nose.
History of presenting illness
This patient has known case of chronic obstructive pulmonary disease (COPD) since 2006.
The patient developed cough and runny nose for 3 days prior to admission after he woke up
in the morning. Then he developed shortness of breath and wheezing in the next day. The
shortness of breath and wheezing gradually worsen at 8.00 am in the morning during the day
of admission.He claimed that his medication (metered dose inhaler) was over for about 2
days. He went to Klinik Kesihatan Bera but unresolved. Then he was referred to Hospital
Temerloh and came here through Emergency Department at 12.00 pm.
The patient claimed that he could not sleep in the night before due to shortness of breath. The
shortness of breath was associated with mild chest pain at both sides of the chest. The
shortness of breath was aggravated by lying flat with one pillow. Thus he has to use two
pillows in order to sleep.
He also had few episodes of syncope due to coughing and shortness of breath in the past one
year. The sputum was white in colour, about one table spoon. He had no hemoptysis. The
episodes of syncope happened when he was doing regular daily activities such as riding the
motorcycle, going to toilet and walking in the house. He also claimed that he had fainted for
about 15 minutes during the way to Hospital Temerloh from Klinik Kesihatan Bera.
During the time of admission, he was alert and conscious. He was very tachpneic and only
able to talk in phrases.
Systemic Review
Gastrointestinal system
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He has no pain at abdomen. No alteration in bowel habit; defecation was about 2 times per
day. There were no vomiting, diarrhea and hematemesis.
Genitourinary system
No alteration in urination habit; urination was about 4-5 times a day. No polydypsia,
hematuria, urgency or urinary incontinence.
Musculoskeletal system
No joints pain or swelling. There also no muscle stiffness and abnormal gait.
Central Nervous System
He had no tremor, loss of sensory, migraine, diplopia, fit, automatism, paralysis, speech
defect or body incoordinations.
Past Medical History
He has no history of hospital admission before. He has a known case of chronic obstructive
pulmonary disease since 2006. He denies any other diseases such as asthma, diabetes mellitus
and hypertension.
Past Surgical History
He had no known past surgical history.
Drug History and allergies
He is under metered dose inhaler (MDI) terbutaline, MDI salbutamol and tablet montelukast
since 2006. He has no known drug allergies.
Family History
He had no known family history of diabetes mellitus and hypertension but his mother had
asthma.
Social History
He is married with 7 children. He is currently living with his wife and one of his children. He
lives in single storey house near Tasik Bera. He worked as a settler. He was a chronic
smoker. He smoked about 40 cigarettes per day in 40 years time.
Physical examination
General inspection
The patient was alert and conscious. He leaned against his bed that was propped up 80
degrees. He was tachpneic and in respiratory distress. He has no chest pain and no
palpitation. He was coughing with minimal sputum on and off.
Vital signs:
Respiratory rate : 33 breath/min
Pulse rate : 134/min Regular rhythm and good volume
Blood pressure : 125/68 mmHg
SpO2 : 108.2 % under Bipap
Temperature : 370C (afebrile)
2
Hands
There was some tar staining at the right side of index finger left side of middle fingers at right
hand. There were no palmar erythema and asterixis. Clubbing were present.
There were no peripheral cyanosis, no clubbing, no pale nailbeds or palmar creases, no
wasting or weakness of small muscle of the hands and no tenderness or swelling of the wrist
joint( hypertrophic pulmonary osteoarthropathy)
Face
No conjuctival pallor, no discolouration of sclera and no evidence of Horner’s syndrome. No
central cyanosis. The hydration and dentition was good. He showed evidence of pursed lips.
Neck
Trachea is not displaced towards one side. Jugular venous pressure was not raised and no
palpable lymph nodes at the neck region.
Specific Respiratory Examination
Inspection
The shape of the chest was normal, no deformities and symmetry bilaterally. No surgical
scar, the skin colour was normal and no visible superficial dilated veins. The accessory
muscle was used to aid in respiration such as sternocleidomastoid, trapezius and abdominal
muscles. No visible pulsation of praecordium.
Palpation
The apex beat is palpable at fifth intercostals spaces at midclavicular line and not displaced.
No parasternal heave and no thrills. Chest expansion was reduced bilaterally. The vocal
fremitus increased bilaterally in front and back of the chest.
Percussion
The sound is resonance throughout the whole lungs for both sides.
Auscultation
There is reduced vesicular breath sound on both sides in front and the back of the chest.
Rhonchi can be heard on both sides at the back. There was increased vocal resonance
bilaterally in front and the back of the chest.
On auscultation of the praecordium, S1 and S2 can be heard over 4 areas. These are mitral,
tricuspid, pulmonary and aortic.
Systemic examination
Cardiovascular
Dual rhythm no murmur
Gastrointestinal tract
Abdomen was soft and non tender. No organomegaly.
Neurological system
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All cranial nerves were intact. The tone was normal. The muscle power 5/5 for all 4 limbs.
Reflexes and sensory component were intact.
Summary
Musa bin Hasan, 52 year old Malay guy complained of coughing and runny nose for 3 days
and shortness of breath for 2 days. He has a known case of chronic obstructive pulmonary
disease since 2006. The shortness of breath was worsening in the morning during the day of
admission. He has no hypertension and diabetes mellitus. He was an active smoker for 40
years. He smoked about 40 cigarettes per day.
Diagnosis
Provisional diagnosis : Acute exacerbation of chronic pulmonary obstructive disease (COPD)
with carbon dioxide retention.
Differential diagnosis : Asthma
COPD
Investigations
Full Blood Count
level Limits units
WBC 9.2 4.0 -10 103/mm3
RBC 4.68 4.5 -6.5 106
HGB 13.6 13.0 – 17.0 g/dL
HCT 41.3 40.0 – 54.0 %
PLT 213 150 – 500 103/mm3
Impression: all the values were in the normal range.
Sputum
Sputum smear was negative.
Impression: no evidence of infection of lower respiratory tract.
Arterial blood gas
PO2 108.2 mmHg
PCO2 56.9 mmHg
pH 7.25
Impression: Respiratory acidosis. This was due to high carbon dioxide retention despite high
oxygen concentration.
Chest X-ray
The chest X-ray taken in anteroposterior position showed the airway located in the middle of
the chest and not deviated. There was no bone fracture. The cardiac size was normal. Both of
the diaphragms were flat. The lungs showed hyperinflation at both sides. There was patchy
haziness at left side of the lung. The costodiaphragmatic angle was poorly defined.
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Impression: The air was trapped in the lung causes tightness of the chest.
ECG
ECG showed sinus rhythm and no ischemic changes. Thus the ECG was normal.
Impression: The cardiac cause can be excluded because the ECG was normal.
Discussion
COPD (Chronic Obstructive Pulmonary Disease) is an umbrella term used to describe lung
disease associated with airflow obstruction. Most generally, emphysema, and chronic
bronchitis, either alone or combined, fall into this category. COPD is caused by long term
exposure to toxic particles and gases most commonly cigarette smoking. However only 10% -
20% of heavy smokers develop COPD, indicating individual susceptibility. The development
of COPD is also related to the number of cigarettes smoked per day.1
The World Health Organization (WHO) estimates that COPD as a single cause of death
shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular
disease and acute respiratory infection). The WHO estimates that in 2000, 2.74 million
people died of COPD worldwide. In 1990, a study by the World Bank and WHO ranked
COPD 12th as a burden of disease; by 2020, it is estimated that COPD will be ranked 5th.
According to the WHO, passive smoking carries serious risks, especially for children and
those chronically exposed. The WHO estimates that passive smoking is associated with a 10
to 43 percent increase in risk of COPD in adults.
In Malaysia, respiratory illness is the primary cause of visits to health clinics and outpatient
hospital clinics. It is estimated that 50 percent of the male population smokes, with higher
rates in the rural areas than the urban areas.2
From the history, physical examination and investigation, the patient Musa bin Hasan had
acute exacerbation of COPD with carbon dioxide retention. The shortness of breath was acute
in onset and associated with wheezing and coughing with minimal sputum. This was not an
asthmatic attack because he has no history of asthma. Furthermore he was a chronic smoker
for about 40 years. There were fingers clubbing.
Pneumonia was unlikely cause because the sputum was white in colour and the smear was
negative. On chest x-ray, the hyperinflated lung was clear.
Plan and management
Chronic obstructive pulmonary disease (COPD) is a common cause of illness in the
community associated mainly with cigarette smoking. It is a progressive disease with
considerable morbidity and mortality. Management of many patients remains suboptimal
because of underdiagnosis and inappropriate treatment. Early detection and appropriate
intervention can minimize the progression of COPD and a comprehensive management plan
benefits all patients, including those with severe disease.
Non-pharmacological
1. Cessation of smoking.
2. Bipap usage. Lower the oxygen concentration gradually.
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3. Exercise and pulmonary rehabilitation.
Pharmacological
1. Iv Aminophylline
2. Iv augmentin
3. T. Clarithromycin
4. Iv Bisolven
5. Mist expectorant
6. T. Zantec
7. Ipratropium
8. Theophylline
References
1. Parven Kumar, Michael Clark. Clinical Medicine, 6th edition: Elsevier , 2008
2. http://www.copd-international.com/library/statistics.htm
3. Huw Llewelyn, Hock Aun Ang, Keir Lewis et al. Oxford Handbook of Clinical
Diagnosis: Oxford
