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COPD Case Study

Patient name: DH
DOB: 7/14
Admit Date: 8/23
Age: 65
Sex: Male
Education: Bachelor's degree
Occupation: Retired manager of local grocery chain
Hours of work: N / A
Household members: Wife age 62, well; four adult children not living in the area
Ethnic background: Asian American
Religious affiliation: Methodist
Referring physician: Marie McFarland, MD (pulmonary)
Chief complaint:
"My husband has had emphysema for many years. He was working in the yard today and
got really short of breath. I called our doctor, and she said to go straight to the
emergency room.
Patient history:
Onset of disease: The patient has a long-standing history of COPD secondary to chronic
tobacco use, 2 PPD for 50 years. He was in his usual state of health today with marked
limitation of his exercise capacity due to dyspnea on exertion. He also notes two-pillow
orthopnea, swelling in both lower extremities. Today, while performing some yard work,
he noted the sudden onset of marked dyspnea. His wife brought him to the emergency
room right away. There, a chest radiograph showed a tension pneumothorax involving
the left lung. Patient also states that he gets cramping in his right calf when he walks.
PMH: Had cholecystectomy 20 years ago. Total dental extraction 5 years ago. Patient
describes
intermittent claudication. Claims to be allergic to penicillin. Diagnosed with emphysema
more than 10 years ago. Has been treated successfully with Combivent (metered dose
inhaler )-2 inhalations qid (each inhalation delivers 18 mcg ipratropium bromide; 130
mcg albuterol sulfate). Diagnosed with Type 2 Diabetes three years ago, treated with
Janumet daily.
Home Meds: Combivent, Lasix, Janumet, O2 2 L/hr via nasal cannula at night
Smoker: Yes, 2 PPD for 50 years
Family Hx: What? Lung cancer Who? Father

Physical exam:
General appearance: Acutely dyspneic Asian American male in acute respiratory distress
Vitals: Temp 97.6F, BP 110/80 mm Hg, HR 118 bpm, RR 36 bpm
Heart: Normal heart sounds; no murmurs or gallops
HEENT: Within normal limits; funduscopic exam reveals AV nicking
Eyes: Pupil reflex normal
Ears: Slight neurosensory deficit
acoustically
Nose: Unremarkable
Genitalia: Unremarkable
Throat: Jugular veins appear distended. Trachea is shifted to the right. Carotids are full,
symmetrical,
and without bruits.
Rectal: Prostate normal; stool hematest
negative
Neurologic: DTR full and symmetric; alert and oriented X 3
Extremities: Cyanosis, 1 + pitting edema
Skin: Warm, dry to touch
Chest/lungs: Hyper resonance to percussion over the left chest anteriorly and posteriorly.
Harsh
inspiratory breath sounds are noted over the right chest with absent sounds on the left.
Using accessory muscles at rest.
Abdomen: Old surgical scar RUQ. No organomegaly or masses. BS reduced.
Circulation: R femoral bruit present. Right PT and DP pulses were absent.

Nutrition Hx:
General: Wife relates general appetite is only fair. Usually, breakfast is the largest meal.
His appetite has been decreased for the past month. She states that his highest weight
was 135 Ibs 6 months ago, but feels he weighs much less than that now.
Usual dietary intake:
AM: Egg, hot cereal, bread or muffin, hot tea (with milk and
Equal)
Lunch: Soup, sandwich, hot tea (with milk and Equal)
Dinner: Small amount of meat, rice, 2-3 kinds of vegetables, hot tea
(milk and Equal)
Food allergies/intolerances/aversions: NKA
Previous nutrition therapy? No, was told to omit potatoes when diagnosed with Type 2
DM.
Food purchase/preparation: Wife
Vit/min intake: None
Anthropometric data: Ht 5' 4", Wt 122 lbs, UBW 135 lbs
Dx: Acute respiratory distress, COPD, peripheral vascular disease with intermittent
claudication, Type 2 DM
Tx Plan:
ABG, pulse oximetry, CBC, chemistry panel, UA

Lab
Sodium
Potassium
Chloride
PO4
Magnesium
Osmolality
CO2
Glucose
BUN
Creatinine
Calcium
ALT
AST
Alk Phos
Albumin
T. Protein
Prealbumin
pH
pCO2
p02
HCO3

Normal
135-145 mEq/L
3.5-5 mEq/L
95-105 mEq/L
2.3-4.7 mg/dL
1.8-3 mg/dL
285-295
mmol/kg/H20
23-30 mEq/L
70-110 mg/dL
8-18 mg/dL
0.6-1.2 mg/dL
9-11 mg/dL
4-36 U/L
0-35 U/L
30-120 U/L
3.5-5 g/dL
6-8 g/dL
18-35 mg/dL
7.35-7.45
35-45 mmHg
>80 mmHg
24-28 mEq/L

Chest X-ray, ECG


Proventil 0.15 in 1.5 mL NS q 30 min X 3 followed
by Proventil 0.3 mL in 3 mL normal saline q 2 hr
per HHN (hand-held nebulizer); Spirogram post
nebulizer Tx
Solumedrol 10-40 mg q 4-6 hr; high dose = 30
mg/kg q 4-6 hr (2 days max), SSI as needed
IVF D5 NS at 75 mL/hr
NPO

Day 1
138
3.9
101
4.5
1.9
293
30
193
9
0.7
9.1
15
12
114
3.2
6.1
16
7.2
65
56
38

Hospital course:

In the emergency room, a chest tube was


inserted into the left thorax with drainage under
suction. Subsequently, the oropharynx was
cleared. A resuscitation bag and mask was used
to ventilate the patient with high-flow oxygen.
Endotracheal intubation was then carried out,
using the laryngoscope so that the trachea could
be directly visualized. The patient was ventilated
with the help of a volume-cycled ventilator.
Ventilation is 7.5 L/min with a Fi02 of 100%, a
positive end-expiratory pressure of 6, and a tidal volume of 700 mL. Respiratory Therapy
and a pulmonologist were consulted for vent management. Daily chest radiographs and
ABGs were used each AM to guide settings on the ventilator.
A nutrition consult was ordered on Day 2 of admission, physician requested TF
recommendations.

Patient Care Summary Sheet


Day:

Temp (C)
Pulse
Respiration
BP
Intake
Oral
IV
TF
Formula/Flu
sh
Shift
Total
Output

Room: 12
Nights
36.6
80

Wt YTDY: 55.5
Days
36.5
85

110/80
NP
O
75

400

Wt Today: 55.5
Evenings
36.7
83

125/92

75

475

117/80

25

25

2
5

75
25

760

4
5

4
5

4
5

--

--

Cath

15
0

Emesis
BM
Drains
Shift
Total
Gain
Loss
Signatures

20
0
2
5

27
5
7
5

30
0
5
0

455

750

-55
Mary Rogers

-275
Linda Clark

20
0

7
5

5
0

12
5

17
5
7
5

725
+35
Jane Patten

7
5