I - Patients Particular

Name
Age
Gender
Race
Marital Status
Occupation
SD number
Date of Admission
Date of clerking

:
:
:
:
:
:
:
:
:

Haniff bin Hassan

65 years old
Male
Malay
Married
Retired
SD00749837
28/9/2015
29/9/2015

II - HISTORY
A - Chief Complaint:
Patient was presented to Emergency Department with the complaint of coughing out blood
one hour prior to admission.
B - History of Presenting Illness:
Patient was well until he developed non-stop coughing at 7.00pm yesterday night. He was
at rest watching television when the symptom occurred. After several harsh coughing, he
coughed up blood, roughly around half a cup. The coughed-up blood was mixed with sputum.
He had had 3 similar episodes on 1972, 1977 and 1989 which ended up in Emergency
Department in different hospitals. He was not able to recall what treatment he was given, what
diagnosis his doctors provided and what medication he had taken. However, he claims that the
doctors suspected Tuberculosis.
For the past two months, he had intermittent dry cough, which was sometimes
accompanied with a streak of blood. The cough was not progressively worsening and
exacerbated by any factors.
Besides that, he claimed to have fever for the past two months. The fever is intermittent in
nature. He went to clinics each time he had fever, however, was denied by the physicians to be
afebrile. He felt tired during each fever, but did not feel cold, sweat and have rigors or chills.
He did not take any medicine to relieve his fever. He noticed loss of weight for the past two
months from 76kg to 70kg. He also complained of loss of appetite.
He have no associated nausea, vomiting, diarrhea or abdominal pain. He also denied of
chest pain and melaena. There was no shortness of breath noted in the past two months. He
denied of any contact with any Tuberculosis patients.
C - Past Medical History:
Patient had been diagnosed to have hypertension for more than 10 years, which he
cannot recall the exact time when he was diagnosed. He had been taking an antihypertensive
drug, but he do not know the name of the drug. He claimed to be compliant to the medication.

Besides that, he denied of other medical illnesses like diabetes mellitus, hypercholesterolemia,
ischemic heart disease and asthma.
D - Past Surgical History:
Patient denied of any surgery done in the past.
E - Drug and Allergy History:
He had been taking an antihypertensive drug, but he was unsure of the name of the
drug. He was compliant to the medication. He denied of the use of other drugs besides the
antihypertensive drug. He denied of the usage of traditional medicine. He did not have any
known allergy to any particular drug.
F - Family History:
Patients family history was not remarkable. All were well and healthy.
G - Social History:
Patient was retired. He lived in Puchong with his first daughter. He was able to perform
activities of daily life and financially supported by his children. There was no financial and
transport problem. He was a smoker but stopped 5 years ago. He was a chronic smoker with
40 pack-year of smoking. He denied of the consumption of alcohol.
I - Systemic Reviews
Nervous System:
He had no history of headaches, dizziness, stroke, weakness or paralysis of upper and lower
limbs, and change in vision, smell and hearing.
Genitourinary System:
He complained of nocturia. Besides that, he was able to pass urine normally without any pain
or difficulty. There was no hematuria noted.
Musculoskeletal System:
There was no symptom of limitation of joint movement, bone and joint pain.
Abdominal System:
There was no abdominal distention or pain. There was also no change in bowel habits.

III - PHYSICAL EXAMINTION:

1. Vital Signs

Temperature
Pulse Rate
Blood Pressure
Respiratory Rate

: 37.1C
: 106 beats/min
: 165/105 mm Hg
: 19/min

SPO2

: 98%

2. General assessments:
Patient was lying 45 degree on the bed with one pillow, alert, conscious and well orientated
to person, time and place. He was well-hydrated and not cachexic. There was no muscle
wasting noted. He was not in respiratory distress but he was tachypneic. There was a cannula
attached to his dorsum of his left hand.
3. Peripheral Examination:
On hand examination, his hands were warm and non-sweating. Capillary refilling time
was less than 2 seconds. There was no clubbing and peripheral cyanosis. Stigmata of infective
endocarditis (splinter haemorrhage, Oslers nodes and Janeways lesion) were not observed.
There was no palmar erythema, leukonychia, dupuytrens contracture and flapping tremor.
There was no tremor on his hand. There was no muscle wasting as well. There was no tattoo,
bruising or scars on his arms. There was a BCG scar on his left arm.
On eye examination, there was no conjunctival pallor and jaundice. There was no
xanthelasmata as well. Oral hygiene was fair and central cyanosis was not noted. There was no
mouth ulcers, leucoplakia or candidiasis. Neck examination revealed that there was no raised
jugular venous pressure. There were no palpable lymph nodes.
On foot examination, there was no pitting oedema.

4. Cardiovascular Systems:
On inspection, the patient was lying 45 degree on the bed. JVP was not raised. The chest
was symmetrical with no visible pulsation. No scars or pacemaker noted in his chest.
On palpation, pulse rate was 106 beats per minute with normal volume and regular rhythm.
There were no radial-radial or radial-femoral delay. Collapsing pulse was absent. Apex beat
was palpable on the 5th intercostal space along mid-clavicular line. No thrill and heave was felt
at the base of heart and parasternal region.
On auscultation, normal S1 and S2 were heard over the mital, tricuspid, aortic and
pulmonary area. No murmur and carotid bruits heard.

5. Respiratory Systems:
On inspection, there was no chest deformity or barrel chest noted. No surgical or traumatic
scars were noted. Both lungs moved symmetrically with respiration. Accessory muscles were
not used for respiration. There were no prominent veins on his chest.

On palpation, the trachea was centrally located and tracheal tug was not noted. There was
reduced chest expansion, however bilaterally equal. Tactile fremitus is equal bilaterally but
increased at the lower zone of the lung.
On percussion, there was dullness in the middle and lower zones of the lung bilaterally.
On auscultation, vesicular breath sound was heard with normal and equal air entry. There
was reduced breath sound and prolonged expiration phase. There was rhonchi heard at the mid
and lower zone of the right lung and the lower zone of the left lung. Coarse crepitation was
heard at base of both lungs.
6. Abdominal Systems:
On inspection, the abdomen was symmetrical and move with respiration. The umbilicus
was centrally located and inverted. There were no dilated veins, hyperpigmentation, or visible
pulsation on the abdomen. There was no scar noted.
On superficial palpation, the abdomen was soft and non-tender. On deep palpation,
there was no palpable mass. Liver was not palpable with liver span 10cm. Spleen was not
palpable. Both kidneys were not ballotable.
On percussion, shifting dullness was negative. Fluid thrill was also negative. On
auscultation, the bowel sound was present and normal. No renal bruit was heard.
7. Neurological:
The patient was able to smell. The visual acuity of the patient was good and the visual field
was normal. Light reflex and corneal reflex were normal. No nystagmus and no diplopia were
noted. The facial sensation and the muscles of facial expression were normal. The hearing of
the patient was normal. Uvula was centrally located and gag reflex was present. Other cranial
nerve examination showed no abnormalities.
No fasciculation and muscle wasting were noted. The tones of upper and lower limbs were
normal. The power of the limbs was good and there was no abnormality with the coordination.
The reflexes were normal. No loss of sensation was noted and no numbness at the periphery.

IV. SUMMARY
A 65-year-old Malay gentleman, ex-chronic smoker, with underlying hypertension for
more than 10 years, was presented with hemoptysis prior to admission, associated with fever
for 2 months, loss of weight and loss of appetite. However, he did not have chest pain, vomiting,
and abdominal pain.
Physical examination revealed that there was reduced breath sound with prolonged
expiration phase, rhonchi and coarse crepitation heard at the lower parts of both lungs. Vocal
fremitus was also increased in lower lung.

V. PROVISIONAL DIAGNOSIS

Lung Carcinoma
Point for

: Repeated Hemoptysis, blood streaking of sputum, pneumonia, weight

loss and loss of appetite, chronic smoker, and chronic dry cough for 2
months

Point against : No dyspnea, no bronchial obstruction, no chest pain

VI. DIFFERENTIAL DIAGNOSIS

1. Bronchiectasis
Point for

: Hemoptysis, chronic cough, coarse inspiratory crepitation and fever,

chronic smoker

Point against

: No purulent sputum, clubbing and wheeze

2. Chronic Obstructive Pulmonary Disease

Point for

: Chronic cough, intermittent hemoptysis, chronic smoker, pneumonia

Point against

: No sputum production, no hyperinflated chest, no sign of right

ventricular failure, no dyspnoea

3. Tuberculosis
Point for

: Chronic cough, hemoptysis, weight loss, pneumonia, fever, chronic smoker

Point against

: No night sweat, no lymphadenopathy

VII. INVESTIGATIONS
1. Full blood count (FBC)
To assess level of Hb level for anemia, white cell count for infection and platelet count.
2. Renal profile (RP)
To assess hydration status and check for any electrolyte imbalance.
3. Liver function test (LFT)
For baseline liver function
4. Coagulation profile
Baseline optimization
5. Chest radiograph
To detect for chest abnormality, consolidations, fibrotic changes or carcinoma

6. Sputum Culture
To detect for infectious agent, especially Tuberculosis
7. Arterial Blood Gases
To check for any acid-base imbalance or respiratory failure
8. Mantoux test
To screen for Tuberculosis
9. Erythrocytes Sedimentation Rate
To check for any inflammatory processes like pneumonia or sarcoidosis.

Results of the Investigations

1. FBC (28/9/2015)
Component
Result
Normal Range
9
White Blood Cells (WBC)
13.3 x 10 /L (4.0-11.0)
Haemoglobin (Hb)
15.5 g/dL
(13.0-18.0)
9
Platelet (Plt)
297 x 10 /L
(150-400)
Haematocrit (Hct)
47.3%
(40-54)
12
Red Blood Cell (RBC)
5.25 x 10 /L (4.50-6.50)
Mean Cell Volume (MCV)
82.5 fL
(76.0-96.0)
Mean Cell Haemoglobin (MCH)
26.9 pg
(27.0-32.0)
Mean Cell Haemoglobin Concentration (MCHC) 32.6 g/dL
(30.0-35.0)
Red Cell Distribution Width (RDW)
13%
(11.6-15.0)
Mean Platelet Volume (MPV)
8.82 fL
(6.3-10.2)
Percentage of Neutrophil
61%
(40-75)
9
Absolute Neutrophil
9.6 x 10 /L
(2.0-7.5)
Percentage of Lymphocyte
27%
(20.0-45.0)
9
Absolute Lymphocyte
3.63 x 10 /L
(1.5-4.0)
Percentage of Monocyte
7%
(2.0-10.0)
9
Absolute Monocyte
0.93 x 10 /L (0.2-0.8)
Percentage of Eosinophil
4%
(1.0-6.0)
Absolute Eosinophil
x 109/L
(0.04-0.4)
Percentage of Basophil
1%
(>0.9%)
Absolute Basophil
0.081 x 109/L (0.02-0.10)
Interpretation:
Patient had a slight high number of white blood cells, indicating that an infection was occurring.
This was supported by the increased absolute neutrophil and absolute monocyte. Patients also
had a deranged mean cell haemoglobin, however, it seemed to be insignificant.
2. Coagulation profile (23/1/2015)
Component
Prothrombin Time (PT)
International Normalized Ratio (INR)
Activated Partial Prothrombin Time
APTT Ratio
Interpretation:

Result
13.3
1.00
39.1
1.3

Normal Range
(11.6-14.7)
(35.0-45.0)

Coagulation profile was all normal.

3. LFT (23/1/2015)
Component
Result
Normal Range
Total Protein
87 g/L
(64-83)
Albumin
34 g/L
(35-50)
Globulin
53 g/L
(34-50)
Albumin/Globulin Ratio
0.64
Total Bilirubin
9.6 umol/L
(3.4-20.5)
Alanine Transaminase
22 U/L
(<42)
Alkaline Phosphatase
97 U/L
(40-150)
Interpretation:
Liver enzymes were normal but albumin was decreased and globulin is increased. This could
be due to overproduction of globin in conditions like systemic lupus erythematous or
underproduction of albumin in conditions like liver cirrhosis or malignancy.
4. Renal profile (23/1/2015)
Component
Result
Normal Range
Urea
5.0 mmol/L
(3.2-9.2)
Sodium
135 mmol/L
(136-145)
Potassium
3.7 mmol/L
(3.5-5.1)
Chloride
102 mmol/L
(96-107)
Creatinine
97 umol/L
(62-115)
Interpretation:
Patient has a slight decreased in sodium level, which is likely to be insignificant.

5. Chest X-ray (20/1/2015)

Interpretation:
This is a PA film, taken while patient is in full inspiration. The trachea is at the midline with
no deformities and paratracheal masses. There is a cavitation at the right middle zone with
some fibrotic changes in the right lung. There was right middle zone consolidation with
bronchiectatic change.
6. Sputum Culture
Component
Date
Result
Gram Stain
30/9/2015
Few Gram +ve cocci bacteria
Sputum Sensitivity
29/9/2015
No recognized pathogens were isolated
Preliminary Result
29/9/2015
No growth after intubation
Interpretation:
There was no recognized pathogens found in sputum. The few gram positive cocci in the
sputum could be infective agent for pneumonia like Steptococcus pneumoniae as supported by
the chest x-ray to have consolidation in the both lower lungs.
7. Erythrocytes Sedimentation Rate (30/9/2015)
Result
Normal Range
80 mm/hr
(2-6)
Interpretation:
The Erythrocytes Sedimentation rate in the patient is very high, indicating a chronic
inflammatory process was occurring like pneumonia.

8. Arterial Blood Gases (28/9/2015)

Component
Result
Normal Range
pH
7.405
(7.350-7.450)
Total Carbon Dioxide
20.4 mmHg
Partial Oxygen
78.3 mmHg
(80-100)
Partial Carbon Dioxide
38.4 mmHg
(35.0-45.0)
Base Excess
-0.9 mmol/L
Bicarbonate (Plasma)
23.5 mmol/L
Oxygen Saturation
95.5%
Lactate (arterial)
2.9 mmol/L
(0.63 2.44)
Interpretation:
Arterial Blood Gases was all well except partial oxygen is slightly lower than normal.
However, there was no breathlessness, increased respiratory rate or usage of accessory muscles
to breathe. Therefore, the slight lower partial oxygen is insignificant in the result.
10. Mantoux Test
Mantoux test was done but he was discharged one day later. The result will be reviewed
in the Klinik Kesihatan two days later
VIII. FINAL DIAGNOSIS
1. Acute Exacerbation of Chronic Obstructive Airway Disease secondary to CommunityAcquired Pneumonia CURB 1 to rule out Pulmonary Tuberculosis

IX. MANAGEMENT
The first intervention of COPD is smoking cessation. It is reported to have great impact
on the natural progression of COPD. Counseling can be done to the smokers, especially to
those who are having COPD to quit smoking by the health care providers. Besides that, nicotine
replacement therapy in forms like nicotine gum and inhaler can be used to overcome tobacco
dependence.
Pharmacologic therapy can be administered in order to reduce symptoms and improve
lung function. Bronchodilators like beta agonist can be used to reduce dynamic hyperinflation
of the lung at rest and exercise. Inhaled glucocorticoids accelerate the rate of
improvement in lung function among these patients. Antibiotics should be given if
there is suspicion of a respiratory infection.
For Acute Exacerbation of COPD, oxygen therapy is administered. However,
controlled oxygen at 24% or 28% should be used with the aim to maintain partial oxygen above
8kPa without worsening acidosis. Bronchodilators and oral prednisolone can also help reduce
symptoms and improves lung function. Non-Invasive Ventilation should be administered if all
of the measures are not enough to improve lung function. Its use is associated with reduced
requirement of mechanical ventilation and reduced mortality.
X. DISCUSSION

According to Global Initiative for Chronic Obstructive Lung Disease report, COPD
(Chronic Obstructive Pulmonary Disease) is a common preventable and treatable disease,
characterized by persistent airflow limitation that is usually progressive and associated with an
enhanced chronic inflammatory response in the airways and the lung to noxious particles or
gases. Globally, COPD has been a leading cause of morbidity and mortality, resulting in
subsequent economic and social burden that is progressively increasing.
It is of the common knowledge that COPD is directly related to the usage of the tobacco
smoking. However, much evidence have shown that non-smokers are at risk of developing
COPD. In many countries, outdoor, occupational and indoor air pollution normally due to the
burning of the wood or biomass fuels are the major COPD risk factors. Gene is also playing a
role in developing COPD, best demonstrated in hereditary deficiency of alpha-1 antitrypsin,
which contributes in a higher risk to develop emphysema. Health aging indicates the sum of
the cumulative exposure to the COPD risk factors. Therefore, age is often listed as the risk
factor of COPD. Some studies even show that women are more prone to have COPD compared
to men. Low birth weight in infants and maternal smoking are confirmed to be associated with
the decline of lung function. Besides that, low socioeconomic status, chronic bronchitis and
recurrent childhood respiratory infections are the other factors that can contribute to the
development of COPD.
Genetic susceptibility and environmental stress to the lung have caused lung
inflammation, accompanied by an increase of oxidative stress, inflammatory cytokines and
protease function. This further results in continued and repeated injury of the bronchial tree as
well as the increased proteolytic destruction of the lung parenchyma. Injuries to the bronchial
tree are normally due to the airway narrowing and fibrosis as a result of the inflammatory cells
infiltrates, like neutrophils and also goblet cells proliferation which subsequently increases
mucus production trapping them in the airways that serve as a place for infection. Meanwhile,
increased proteolytic destruction of lung parenchyma reduces airway elasticity, decreases
structural support for airway patency and also causes permanent enlargement of the alveoli.
These causes air trapping within the lung, lung hyperinflated and airway narrowing and
collapse. These result in chronic bronchitis and emphysema which subsequently cause COPD
in the late stage.
If a patient found to be 40 years old and above with the symptom of chronic bronchitis
and breathlessness, COPD is normally the provisional diagnosis, which comes before other
diagnoses like tuberculosis, chronic asthma and bronchiectasis. Generally, chronic cough and
sputum production are the first symptoms to be encountered. The cough is initially intermittent
and non-productive but in later stage it will be present every day. Dyspnea is associated with
the increased effort to ventilate the lung. As time progresses, the chest has to expand more in
order to breathe causing barrel chest and further inspiratory effort will contract the diaphragm
The narrowed airway can sometimes cause turbulent flow which results in expiratory
wheezing.

Clinical diagnosis is made from the history and the spirometry test. In a patient who has
the history of dyspnea, chronic cough or sputum production, accompanied with a history of
risk factors for the disease like cigarette smoking or occupational exposure to noxious particles,
COPD should be highly considered. Clinically, the presence of a bronchodilator of FEV1/FVC
< 0.70 is diagnostic of COPD. The severity of the COPD is assessed by the degree of
breathlessness and FEV1.

Acute exacerbation of COPD is characterized by the increased respiratory symptoms

and deterioration of the lung function. The triggers could be variable, from the infection with
bacteria or virus to sudden change in air quality. These generally cause increased inflammation
which increases hyperinflation of the lung and air trapping, leading to increased dyspnea.
Sometimes, hemoptypsis can occur. Other condition like, pneumonia, thromboembolism and
acute heart failure can aggravate COPD.
In this case, patient was presented with hemoptysis for 1 hour prior to admission,
complained of chronic cough and fever for the past 2 months. Weight loss and loss of appetite
were noted as well. My provisional diagnosis based on the history was lung carcinoma. Chronic
cough and hemoptysis accompanied by constitutional symptoms like fever, weight loss and
loss of appetite strongly suggest lung carcinoma.
During the investigation, chest x-ray suggested chronic pneumonia was occurring in
the patients lung. There is a cavitation at the right middle zone which may indicate lung
abscess with some fibrotic changes in the right lung. There was right middle zone
consolidation with bronchiectatic change. There was no hilar enlargement or tumour seen in
the x-ray.
The result of the sputum culture yielded the result of a few gram positive cocci which
can indicate Streptococcus pneumoniae infection, which is one of the common cause of
community-acquired pneumonia. This is supported by no recent hospitalizations or recent
contact with medical professionals which could lead to hospital-acquired pneumonia. Patient
complained of fever and cough for 2 months, which support the idea of infection occurring in
the lung.
XI. REFERENCE

1. Vinay Kumar, MD, FRCP, Professor of Pathology, University of Chicago. Robbins Basic
Pathology. Publihed by the Suanders, an imprint of Elsevier. 7th edition. Page 495
2. Christopher Haslett et al. Davidsons Principles and Practice of Medicine. Published by
Churchill Livingstone. 20th edition. Page 694