Acute Exacerbation of COPD secondary to HAP

Click to edit Master subtitle style 0910886 Siti Najwa Binti Mohd. Nasir
Elina Binti Sahidan 0916280 Muhammad Nur Izzat Bin Ibrahim 0913239
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Case Summary
This is a case of acute exacerbation of Chronic Obstructive Pulmonary Disease secondary to Hospital Acquired Pneumonia.

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Patient Demographic
Name Age Weight Height Gender Race Ward

: MJM : 72 yrs old : 64 kg : 140 cm : Male : Malay : Kenanga 12 : 06/10/2011 : 13/10/2011

Date Of Admission

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The shortness of breath last for two days and

History of Presenting Illness

worsen at todays evening. It is relieved for about 5 minutes upon taking metered-dose inhaler. sputum

It is associated with coughs with minimal Reduced effort tolerance for two days. Orthopnea and paroxysimal nocturnal

dyspnea.
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Past Medical History

Disease/conditions
1.

Duration
-

HTN COAD Bronchiectasis CCF Acute confusional state

6 years 13 years 5 years

1.

1.

1.

1.

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Past Medication History

Prescription medications 1. T. Telmisartan 1. MDI Salbutamol 1. MDI Budesonide 1. MDI SPIRIVA 1. T. Frusemide 1. T. Risperidone 5/5/12

Dosing regimen 80 mg od 2 puff prn 2 puff bd Every morning 40 mg od 0.5 mg od

Indication Hypertension Acute SOB Control of SOB Control of SOB Hypertension Acute confusional state

Social, Occupational and Family History

Social history:
Smoke 20 packs of cigarettes daily 54 years ago. Had stop 5 years ago when started to fall sick.

Occupational history:
Formerly was a log cutter. Highly exposed to dust.

Family history:
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No significant family history

Medication Adherence History

Patient information relevant to medication adherence:
Poor memory Can read and understand Malay Has difficulty in hearing and vision The medication is taken care by his wife Store the medication in the drawer

Patient has no risk factor that affect adherence

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Review of Systems
System Vital signs CNS Psych CVS Pulmonary Renal GI Fluid/elctrolytes 5/5/12 Remark BP 144/ 68 mm Hg HR 94 beats/min RR 23 breaths/min patient is alert and conscious normal DRNM, sinus rythm Coarse crepitation, no ronchi Normal (Passed Urine is normal) Bowel output normal, no diarrhea Hydration is fair

Provisional Diagnosis
AECOPD 2 at hospital acquired pneumonia Bronchiectasis Mild renal impairment 2 to dehydration

(ACEI), v/l CCF, HPT, bronchiectasis

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Vital Sign
Parameters Reference Range Day 1 06/10 37 144 /68 60-100 /min 12-20 /min 95-99% 94 23 93 Day 2 07/10 37 137 /69 89 93 22 97 Day 3 08/10 37 125 /65 87 89 22 95 Day 4 09/10 37 134 /66 82 92 22 96 Day 5 10/10 37 158 /70 97 88 21 100 Day 6 11/10 37 150/ 70 97 81 20 93 Day 7 12/10 37 150 /70 97 90 22 96 Temperatur 37.2 C e Blood Pressure MAP Pulse Rate Respiration Rate SP02 130/80 mmHg

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Comment:
The body temperature was 37.0 C and the patient was afebrile (without fever). From the data, the systolic blood pressure was mostly high while the diastolic blood pressure was maintained below 80mmHg. Normally, the recommended goal for systolic pressure is less than 140 mm Hg. When the systolic pressure is above 140 mm Hg with a diastolic pressure that still is below 90 the patient probably has isolated systolic hypertension. However, for people 70 years old and older, a goal of less than 150 mm Hg is advised. Thus, it might be normal for this 72 years old -patient to have systolic blood pressure more than 140mmHg. The respiration rate was mostly high might be because of condition of chronic obstructive pulmonary disorders (COPD) that make it hard for the patient to breath. 5/5/12

BUSE/Renal Profile
Reference Parameter Range BUN Serum sodium Serum potassium Serum chloride Creatinine Creatinine Clearance 5/5/12 2.5 -7.5 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 95-108 mmol/L 44-133 mol/L 105-150 ml/min Date

8/10/11 10.9 145 4.9 97 134 39.95

9/10/11 9 146 3.5 97 118 45.36

10/10/11 11/10/11 9.3 148 4.4 98 110 48.66 14 138 4.5 94 172 31.12

Comment:
The Creatinine clearance values are very low. This suggests

that patient is having stage 3 chronic kidney disease.

BUN level is also high because patient kidney fails to

excrete urea from plasma.

Serum sodium increased might be due to effect of

corticosteroid intake (budesonide and prednisolone) and renal impairment.

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Arterial Blood Gases

Parameter pH pCO2 pO2 HCO3 sO2 saturation Reference Range 7.35-7.45 35-45mmHg 83103mmHg 22-26mEq/L 95-98% Date 7/10/11 7.29 72.9 84 34.3 95 8/10/11 7.26 88.4 54 38 82 9/10/11 7.33 75.7 65 38.6 0 10/10/11 7.31 86.5 35 42.6 0 11/10/11 12/10/11 7.34 65.5 87 34.5 96 7.32 71.8 75 36.3 94

Comment: pH value is lower than normal range. From the high value of pCO2 patient is having respiratory acidosis with compensation by the kidney indicated by high value of HCO35/5/12

Full Blood Count

Date Parameter WBC RBC Hgb Plt MCV MCH MCHC Neu Lymp Monocyte 5/5/12 Reference Range 4.5 11.0x109/L 4-4.9 x1011/L 12.0 15.0g/dL 150 450x109/L 78-100m3 25-35pg/cell 31-37g/dl 40-75% 20-51% 2.00-10.00 % 4/10/11 7.2 5.48 16.4 251 95 29.9 31.6 60.9 22.0 11.0 6/10/11 10.2 5.24 16.3 230 99 31.1 31.3 61.3 23.1 10.2 11/10/11 10.0 5.17 15.5 165 93 29.9 32.2 72.2 15.4 10.8

Comment:
This test was done to screen for infection within the system. Most parameters were within normal ranges. Only some

parameter shown some slight deviation from normal ranges (in this table: monocyte, lymphocyte).
The deviation was considered clinically insignificant as the

values only fluctuate a little from the upper or lower of the limits of reference ranges. Therefore, the FBC was normal.

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