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Case Summary of Patient With Chronic Obstructive Pulmonary
Case Summary of Patient With Chronic Obstructive Pulmonary
1) CASE SUMMARY
Mr TLT is a 58 year old taxi driver who was admitted to Hospital Batu Pahat due to newly
diagnosed chronic obstructive pulmonary disease.
He has had hypertension for the past one year and is taking T Amlodipine 5mg od. He is also a
chronic smoker for the past 40 years who smokes about 20 sticks of cigarettes a day.
Mr TLT presented with shortness of breath which progressively increased in severity for the past
4 days. The shortness of breath was associated with a wheeze. There was also cough with
production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory
tract infection.
Mr TLT has been having intermittent chronic cough associtaed with mucoid sputum for the past
3 years. He has also been having persistent breathlessness for the past 1 year especially on
exertion. He has not sought treatment prior to this admission.
On physical examination, Mr TLT was tacypnoiec with a respiratory rate of 28 breaths per
minute. There was no cyanosis. Repiratory system examination showed use of accesory
muscles as well as increased anterior posterior diameter of the chest and reduced cricosternal
distance. On auscultation, vesicular breathing was heard with generalised rhonchi and coarse
early inspiratory crepitations at the lower zone of both lungs. The cardiovascular system
examination was normal. There were no other abnormalities on physical examination.
PATIENT'S DETAILS
I/C NUMBER : 510912-01-6343 AGE : 58
SEX : Male DATE OF ADMISSION : 2 June 2009
R/N NUMBER : 1143451
CLINICAL HISTORY
Chief complaint:
Mr TLT is a 58 year old taxi driver who presented with
shortness of breath for the past four days.
FINDINGS ON CLINICAL
EXAMINATION
On general examination, Mr TLT was well nourished and alert but
was tachypnoiec. He was able to speak in sentences but there was
use of his accessory muscles. There was no clubbing or cyanosis
seen. There was also no peripheral oedema, pallor or jaundice.
Vital signs:
Pulse rate: 72 beats per minute, regular with good volume. No
bounding pulse.
Respiratory rate: 28 breaths per minute
Blood pressure: 129/73
Temperature: 37 degrees Celsius
SpO2: 95% under nasal prong oxygen 3 litres per minute
Differential diagnosis:
1) Congestive cardiac failure.
Mr TLT may have developed congestive cardiac failure as a primary event or as a complication of chronic lung disease.
There is history of reduced effort tolerance. Patients with congestive cardiac failure may also present with a wheeze and
sudden increase in dyspnoea. Physical examination of fine crepitations at both bases of the lungs may also indicate
congestive cardiac failure. There is also evidence of mildly raised JVP as well as mild pittint ankle oedema.
Evidence against:
There is no history of any cause of heart failure such as ischaemic heart disease or cardiac valve defect. Mr TLT's
previous records during follow-up show well controlled blood pressure.
Additional investigations need to be carried out in order to rule out this condition. A chest plain radiograph may be done
in order to look for evidence of heart failure such as cardiomegaly. An ECG may be done to look for right atrial
hypertrophy. An echocardiogram should also be performed in order to assess the function of the ventricles.
2) Bronchiectasis
Patients with bronchiectasis have a history of chronic cough as well as production of copious amounts of sputum. They
may also have persistent shortness of breath, reduced effort tolerance and wheeze.
Evidence against:
The sputum produced by Mr TLT is mucoid in nature and not purulent which is typical in bronchiectasis. It is also not
copious and foul smelling in nature. On physical examination, coarse crepitations would be heard in bronchiectasis as
opposed to the fine crepitations heard in Mr TLT. There is also no evidence of clubbing.
Chest plain radiograph should be done in order to look for thickened bronchial walls or cystic shadows.
6) Electrocardiogram
Justification: To look for evidence of right ventricular
hypertrophy or right atrial hypertrophy which may be
seen in chronic lung disease.
Results: ECG with sinus rhythm. There is no P pulmonale
seen. There is low voltage seen. No ischaemic changes
seen. No left ventricular hypertrophy.
Interpretation: Normal ECG with low voltage is seen in a
hyperinflated chest such as in patients with COPD