Mr.Z.

A , a 62 years old Malay man with background history of COPD , presented at emergency
with complaints of shortness of breath exacerbated from 5 dyas and progressive worsening of
cough since 1 week ago.

HOPI
SOB
My patient is known to have episodes of breathlessness with wheeze for the last 10-15 yrs
which was insidious in onset & gradually progressive ,in which during this episode patient
complains of breathlessness worsening 5 days back to cause breathlessness at resting and
associated with wheeze during episodes of breathless

Aggravates in cold weather,more in the morning and exposure to dust and slightly relieved on
bending forward.The patient denied any pets at home.During this current episode,The patient
complains that SOB is likely exacerbated due to the rainy season.

Initial few years of his symptoms were mild, in which it was present on doing moderate heavy
work,however for the last 5 years,he had more aggravation of symptoms necessitating multiple
hospitalisation where he would receive nebulisation for relief.From the past 1 year,patient has
been on home nebulisation.His symptoms gradually progressed so that even in between the
attacks ,he could do only less than moderate work & during episodes of worsening,he was
symptomatic even at rest,preventing him to do his activity of daily living such such dressing
himself and going to the toilet.It is present intermittently throughout the day. He scored 3 on the
modified Medical Research Council (mMRC) scale, indicating she is unable to walk a few
minutes on level ground and sometimes 4 indicated breathless to leave the house or dressing.

ORTHOPNEA
He uses 2 pillow to sleep at night pass 5 years but did not increassdd in severity ,has he denied
increased in the need of number of pillows.Along with that he also denies lower extremity
swelling..

COUGH
The SOB is usually associated with Wworsening of cough with scanty, viscid/mucoid sputum.
past 1 week
● The patient had past 5 years intermittently throughout the day,however since the past 3
days ,gradually progressive
● Associated with scanty amount of sputum,white in colour,mucoid in consistency,not
blood tinged or foul smelling.Increased in volume of sputum over the past 3 years.
● Cough aggravated in cold weather ,more in the morning with no positional variation.
The relevant negative symptoms are
-fever,chest pain,rhinitis/sinusitus,purulent sputum and hemoptysis

Currently has sudden exacerbation of symptoms from last 6 days , present throughout the day
intermittently limiting his daily activities.However, there is no history of fever, purulent sputum,
hemoptysis .

Past medical history /Hopisalisation/Medications/surger y

1.The patient has been diagnosed with childhood asthma at the age of 10 years old.
2.The patient has been diagnosed with COPD ( GOLD D -fev1<30) 11 years ago.He has MMRC
score between 3-4.
3.Hypercholesterolemia diagnosed 10 years ago
3.The patient also has been diagnosed with gastritis 8 years ago.
4.There is no history of tuberculosis in past and family

Hospitalisation

For the last 5 years, he had more aggravation of symptoms necessitating multiple
hospitalisation where he would receive nebulisation for relief.The patient reports to have at least
1 admission to the hospital due to acute exacerbation of asthma of the age of 28 since
diagnosed at 10 years old.After the age of 28 years old, the reports to have at least twice
admission to the hospital due to the asthma.However ,since the copd was diagnosed patient
required multiple admission which was worse at the 2020,whereby it required 5 times of
hospitalisation and also required intubation for one of those episodes in 2012. Of note , the
recent episodes of hospitalisations were comparatively more severe than previous episodes..IN
2021 ,he has had 5 exacerbations in the past year, three of which were treated with antibiotics
and oral steroids His last admission was on 15/12-21/12 for AECOAD secondary to CAP.

● On ultiniobreezehaler 1 capsule OD
 ● MDi(metered dose inhaler) budesonide 2 puffs BD

● MDi salbutamol 2 puffs PRN

● Neb combivent 11/11 4 times per day

● Theophylline 250mg BD

● Bromohexine 8 mg

MEDICATIONS
Her current medications include
a. On ultiniobreezehaler 1 capsule once daily, -LABA
b.MDi(metered dose inhaler) budesonide inhaled 2 puffs , twice times per day,
c.. MDi salbutamol 2 puffs PRN.
He explained that his breathing had improved slightly since taking his preventer inhaler (ICS)
more regularly, although he was still troubled by symptoms and needed to use his SABA rescue
inhaler at least six times a week .
d.Neb combivent 11/11 4hrs
Combivent (metered dose inhaler )-
2 inhalations
qid (each inhalation-delivers 18 mcg ipratropium bromide;

e.Theophylline 250mg BD
F.Bromohexine 8 mg TDS (mucolytics)
f.Atorvastatin 20 mg once daily
g.pantoprazole 40mg once daily
Apart from these medications, he took no other herbal remedies .

LTOT
The patient does not use oxygen at home( long term oxygen therapy )

VACCINE
The patient keeps up to date with her seasonal influenza and pneumococcus vaccinations.
The patients been taking influenza vaccine annually for the past 7 years and pneumococcal
vaccine every 5 years ,twice for the past 10 years.His last influenza vaccine 5th April 2021.
His pneumococcal vaccine is on 20th September 2021.The patient also completed the covid
vaccination(pfizer) ,including the booster shot ,2 months ago.
No history of prior surgeries
-no history of surgeries

Allergies
The patient has allergies to chicken and seafood, .The patients reports to have ezcema over
the hands and feets.

Social history
The patient has 40 packs history of smoking,until the age of 59 where he cut down to 5 sticks
per day. for the past 3 years .He denies any consumption of alcohol and any use of elicit drugs
in the past.In the past, the patient had tried stopping smoking through will power alone, but had
never succeeded in staying smoke-free.The patient married with 6 children .The patient worked
as a bus driver in the past and no exposure to any

Family
• Family History has significant family history of lung cancer in which his brother had lung
cancer and died at the age 56
- Patient has 9 siblings and the patient is the 6th in the family.
- Other 4 siblings died respective at the age of 65 due to CKD,71 due heart disease and
65 due to stroke and 67 due to colon cancer and the 4 sibling are has diabetes and
hypertension.
– Father died of myocardial infarction at age 72 years (diabetes, hypertension, smoker)
– Mother alive mother died due to breast cancer at 66.
– Children are doing well with no underlying comorbidities

Physical Exam
Initial physical exam reveals
temperature 37. C,
Pulse rate 88 bpm, normal volume
respiratory rate 24,
BP 121/68,
BMI 40.2, and
O2 saturation 95% on room air.
General:,
The patient is alert,concious and orieted and appears to be a normal built,. Lying comfortably at
45 degrees.Not in obvioius respiratoty distress. No pallor,cyanosis, jaundice or use of accessory
muscles of respiration.

● Hand: No peripheral cyanosis,no clubbing,no tar staining, capillary refills normal and is
fine tremor when hands in an outstercted position ,however there is no flapping tremor
● Mouth: Moist mucous membranes,no central cynosis, normal dental hygiene
● Eyes:No Conjunctiva pallor and No scleral icterus.\
● Neck: Trachea is located at the midline and presence of tracheal tug,downward
movement of trachea during inspiration-downward pulls due to depressed diaphragm,No
raised JVP

Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+
pitting edema bilateral lower extremities and strong pulses in all four extremities.
Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing
noted, bilateral rhonchi, decreased air movement bilaterally. Patient barely able to finish a full
sentence due to shortness of breath.
Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losse

Respiratory
Inspection
-Chest wall moving symmetrically
-No increased in AP diameter
-No intercostal indrawing
-No visible pulsation,scars
-No chest deformity or kyphosis or scoliosis
-At the axilla there is presence of a 10cm x 5 cm in size of mass located on he right axilla 10 cm
below the armpit,lobular in shape, fluctuant,slightly mobile, not fixed to the skin, no local
tenderness and no change in the color of the skin and non tender.

Palpation.
.The apex beat is located at 5th intercostal space midclavicular line
-the chest expansion is normal about 3cm anteriorly and posterior ,equal bilaterally
-Tactile fremitus is normal equally bilaterally
-There is no palpable lymph nodes

Percussion
The percussion notes was resonant throughout the chest

Ausculattaion
-Generalised rhonchi heard, equal air entry
(continous,low pitch breath sounds heard at inspiration ,sound often from copious secretion in
large airways or bronchi)
-S1,S2 is heard and no murmurs.
-No pitting edema

Summary
In summary,patient 67 year old Malay man with a background history of COPD( gold D)
11years ago with underlying 40 pack year of smoking and hypercholestromia and significant
family history of lung cancer in brother,presented to to the emergency department with
complaint of worsening shortness of breathless for 5 days and progresive worsening of cough
with white sputum without presence of blood associated with wheeze.He scored 3 on the
modified Medical Research Council (mMRC) scale.Horever, there is no orthopenea,PND and
limb swelling suggesting cor pulmole.
COPD
● This was associated with a wheeze Aggravated due to exposure to cold weather
symptoms suggest that it was the trigger for this episode of exacerbation.
● He denies chest pain, fever, chills,
ASTHMA
He had multiple admission in the past due to similar complaints and his last hospitalization was 2
weeks ago secondary to community acquired pneumonia. He uses a nebulized
combivent( salbutamol + ipratropium) 4-6 times a day and uses a short acting beta agonist 6
times per week with limited relief.
LUNG MALIGNANCY
No history of loss of appetiteand weight loss -suggesting malignancy

DDx1.non infective acute exacerbation of COPD without evidence

of cor pulmole or respiratory failure
Evidence for:
● Patients with chronic obstructive airway disease (COPD) usually present with a
persistent dyspnoea and reduced effort tolerance which was present in the history given
by Mr k..
● He is also at increased risk of developing COPD due to exposure to associated risk
factors such as tobacco smoke.
● He has been a chronic smoker for the past 40 years.
● There is also the presence of chronic cough occasionally associated with mucoid
sputum which further suggests COPD.
● Physical findings of vesicular breathing with generalised expiratory rhonchi also point to
an obstructive airway disease.
● During this admission Mr TLT had increasing severity of shortness of breath even at
rest. This was associated with a wheeze that was described as noisy breathing.
● Sudden worsening of symptoms suggest an episode of acute exacerbation.
● The history of exposure to cold weather symptoms suggest that it was the trigger for this
episode of exacerbation.
2.LUNG MALIGNANCY
No history of loss of appetiteand weight loss -suggesting malignancy

3.) 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.

4.) 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.
1) Full Blood Count Justification: In order to view the total white count as well as the
differential count to see if there is an infection which has caused this episode of
exacerbation. There may also be secondary polycythemia if the patient has chronic
pulmonary hypertension.

2) Plain chest radiograph—-Justification: Done in order to look for evidence of chronic

obstructive airway disease such as hyperinflated chest or evidence of congestive
cardiac failure such as cardiomegaly and prominent upper lobe vessels.

Results: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No
other abnormalities seen.

Interpretation: Hyperinflation of the lung fields is consistent with the provisional

diagnosis of chronic obstructive airway disease.
3) Sputum FEME, culture and sensitivity (not done)----Justification: In order to look for
any bacteria which may have been the cause of the exacerbation . If there any organism
cultured, proper antibiotics can be given based on the sensitivity test.

4) Arterial blood gas (not done)----Justification: May be necessary in severe cases of

breathlessness to look for respiratory failure and associated changes in blood pH.

5) Blood urea serum electrolytes and creatinine—-Justification: To look for renal

impairment which may be present due to Mr TLT having hypertension. Renal
impairment may also affect the dosage and type of antibiotics used.

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

Management

Acute management

1. Provide supplemental oxygen via nasal prong 3L/min and maintain SpO2 above 90%.
Arterial blood gas should be done in order to ensure adequate oxygenation without
carbon dioxide retention of acidosis.

2. Close monitoring of vital signs and SpO2 hourly until the patient’s breathlessness
improves. Nursing staff to inform if patient deteriorates such as increased respiratory
rate or drop in oxygen saturation below 92%.

3. Give nebulization of Ipratropium Bromide:Salbutamol:Normal Saline-treat mucous

hypersecretion in ratio of 2:2:1 every four hours until breathlessness decreases.
4. Oral prednisolone 40mg once daily for 10 days

5. Postural drainage and chest physiotherapy may be performed.

6. Oral antibiotics such as T. Cefuroxime may be given. This was not given in this
patient with further discussion below.