CASE:

Grace Marcelino from matang tubig San Rafael Bulacan seek consultation at Castro
Maternity and General Hospital last October 15 ,2020 A widowed, 60-year-old, retired
elememtary teacher her main complaint is breathlessness after moderate exertion. She
scored 3 on the modified Medical Research Council (mMRC) scale (Fletcher et al, 1959),
indicating she is unable to walk more than 100 yards without stopping due to
breathlessness. Ms Marcelino also has a cough that produces yellow sputum (particularly
in the mornings) and an intermittent wheeze. Her symptoms have worsened over the last
six months. She feels anxious leaving the house alone because of her breathlessness and
reduced exercise tolerance, and scored 26 on the COPD Assessment Test (CAT,
catestonline.org), indicating a high level of impact. Ms Marcelino smokes 10 cigarettes a
day and has a pack-year score of 29. She has not experienced any haemoptysis (coughing
up blood) or chest pain, and her weight is stable; a body mass index of 40kg/m2 means
she is classified as obese. She has had three exacerbations of COPD in the previous 12
months, each managed in the community with antibiotics, steroids and salbutamol.
Mrs. Marcelino has been prescribed inhaled salbutamol (SABA)(ASMALAL) at 2 puffs
PRN up to 4x a day when needed and Formoterol Fum.(Tioform) 12ug O.D At a routine
review, Ms Marcelino admitted to only using the SABA and LAMA inhalers, despite
also being prescribed a combined inhaled corticosteroid and longacting beta2 -agonist
(ICS/LABA) inhaler.
On physical examination, the patient was afebrile and in no respiratory distress. Her
blood pressure reads 120 / 90 mmhg There was no cyanosis or jugular venous distention
nor were there palpable masses or lymphadenopathy in the neck. Lung sounds were
vesicular but were somewhat diminished bilaterally. The patient's heart sounds and
findings from an abdominal examination and examination of his extremities were
unremarkable.

Upon admission Dr. Herrera requested for chest x-ray and spirometry testing ..He also
ordered to start venoclysis of PLRS il at KVO rate . O2 inhalation at 2-3/ Lpm via nasal
cannula . an initial dose of Hydrocortisone 200 mg TIV is to be given , then 100 mg q 8
X 3 doses then switch to prednisone 30 mg p.o O.D ,budesonide 1 respule q 8hrs .
Since the symptoms have been quite sometime an initial loading of amoxicillin
clavulanate 500mg TIV q 8 is also given and azithromycin 500 mg tab O.D for 5 days
..advised to continue her inhaler as needed . she is on DAT with SAP and was ordered
CPT after each nebulization..She is also on ABG monitoring .
Mrs. Marcelino was also requested with spirometry testing and the results showed an
FEV1/FVC of 56% and a predicted FEV1 of 57%, with no significant improvement in
these values with a reversibility test.
A radiograph of the chest was significant for hyperinflated lung fields but did not show
any parenchymal abnormalities. Blood work revealed mild neutrophilic leukocytosis.
Bronchoscopy was requested to rule out any upper airway obstruction .
 His father died of ischaemic heart disease and emphysema at the age of 67 years. Mrs
Marcelino has no known allergies to food or medication ..she had 2 scesarian section 3
decade ago.. other than that she had no major hospitalization . as for vaccinations Ms
marcelino keeps up to date with her seasonal influenza but has missed out pneumococcus
vaccinations because of financial constrain .
Based on the patient's symptoms, medical history, physical examinations, and
laboratory tests, Mrs marcelino has COPD/ emphysema moderate