Case Presentation and Discussion

on Chronic Obstructive Pulmonary

Disease

Submitted by:
Rania I. Askali
ADZU SOM- Level III
CASE PRESENTATION

This is a case of E.C, a 78-year old female from Cabatangan, Zamboanga

City. She is a elementary school graduate and a Roman Catholic.

CHIEF COMPLAINT: Difficulty of Breathing

HISTORY OF PRESENT ILLNESS:

Patient was apparently well until 2 days prior to admission, patient had an onset of

productive cough with whitish sputum, associated with difficulty of breathing. She had no fever,

no pleuritic pain and no hemoptysis. Patient nebulized at home with 3 nebules of Salbutamol

plus Ipratropium, which afforded temporary relief. On the morning prior to admission, she had

productive cough with difficulty of breathing and was not associated with fever, pleuritic pain

and hemoptysis. This prompted consult at the ZCMC OPD, where she was referred to the E.R for

further evaluation and management. She was initially treated with 3 nebules of Salbutamol plus

Ipratropium, which provided no relief of dyspnea. Hence, she was advised admission.

PAST MEDICAL HISTORY:

Patient is a known Asthmatic since 2018 and has been taking Montelukast, Cetirizine and

Salmeterol+Fluticasone inhaler. Accordingly, she is non-compliant to her Asthma medications.

She was previously admitted last February due to Chronic Obstructive Pulmonary Disease.

Patient has no known comorbidities such as hypertension and diabetes mellitus and no known

allergies to food or medications.

FAMILY HISTORY:

Patient’s paternal side has a history of bronchial asthma. No other heredofamilial diseases

such as Diabetes Mellitus, hypertension and cancer were reported.

PERSONAL AND SOCIAL HISTORY:

Patient is a widow and currently lives with her son and his family. Patient denies smoking

and drinking of alcoholic beverages, but with exposure to second-hand cigarette smoking. She

also uses firewood for cooking since childhood. Her usual diet consists of rice, vegetables and

fish.

REVIEW OF SYSTEMS

(-) Fever
GENERAL (-) Weight Loss
(-) Fatigue
(-) Rashes (-) Lumps (-) Sores (-) Itching
SKIN
(+) Dryness (-) Color change
Head: (-) Injury (-) Dizziness
(-) Lightheadedness
Eyes: (-) Blurred vision (-) Pain (-) Excessive tearing
HEAD, EYES, EARS,
Ears: (-) Discharges (-) Earache (-) Tinnitus
NOSE AND THROAT
Nose and Sinuses: (-) Epistaxis (-) Pain (-) Discharges
(HEENT)
(-) Itching (+) Frequent colds
Throat:(-) Sore throat (-) Hoarseness (-) Bleeding gums
(-) Dentures (-) Sore tongue (-) Dry mouth
NECK (-) Stiffness (-) Nape pain (-) Swollen glands (-) Goiter
(+) Exertional Dyspnea for 3 months
RESPIRATORY
(-) Hemoptysis (-) Pain
CARDIOVASCULAR (-) Palpitations
(-) Pain with defecation
GASTROINTESTINAL
(-) Rectal bleeding (-) Abdominal pain
PERIPHERAL (-) Claudication (-) Leg cramps (-) Swelling (-) Tenderness
VASCULAR (-) Varicose veins
(-) Frequent urination (-) Burning or pain during urination
URINARY
(-) Hematuria (-) Flank pain
(-) Muscle or joint pain (-) Stiffness (-) Arthritis
MUSCULOSKELETA
(-) Backache (-) Pain (-) Tenderness (-) Swelling
L
(-) Limitation of motion or action
(-) Slurred speech (-) Paralysis
NEUROLOGIC
(-) Seizure
(-) Excessive sweating (-) Excessive thirst or hunger
ENDOCRINE
(-) Heat or cold intolerance

PHYSICAL EXAMINATION
 Seen and examined patient seated on chair. Awake, alert, oriented
GENERAL
to 3 spheres, in mild respiratory distress. Noted on tripod position.
Temperature: 36.2˚C Pulse Rate: 76 bpm
VITAL SIGNS Respiratory Rate: 24/min O2 sat: 97% at room air
Blood pressure: 100/60 mmHg
No scars, jaundice or cyanosis noted. Skin is warm to touch with
SKIN
good skin turgor.
Head: The head is normocephalic and atraumatic with equal hair
distribution. No lumps or areas of tenderness were palpated.
Eyes: Anicteric sclerae. Pupils equally reactive to light and
HEENT accomodation; with pink palpebral conjunctiva.
Ears: No deformities or discharges noted.
Nose/Sinuses: No nasal discharges, no nasal flaring
Throat: No tonsilopharyngeal swelling.
NECK No swollen glands, no lymphadenopathies.
LUNGS AND THORAX: Equal chest expansion with no
retractions. Palpation and percussion not done. Fine crackles
auscultated at left upper lung field with expiratory wheezes on both
CHEST lung fields.
CARDIOVASCULAR: Adynamic precordium. PMI palpated at 5th
ICS MCL. No heaves and thrills. S1 and S2 sounds distinct and
regular, no murmurs.
Abdomen appears flat with no distention. Bowel sounds
ABDOMEN normoactive at 12 clicks per minute. Soft on palpation, no
tenderness, no organomegaly.
PERIPHERAL Capillary refill time is less than 2 seconds, no edema.
VASCULAR

CASE DISCUSSION

I. Clinical Diagnosis

Cues:

Patient Demographics History Physical Examination

 78-year-old  Onset of productive cough  Seated on tripod
Female with difficulty of position
breathing  Tachypnea at 24
 Known Asthmatic breaths/min
 Admitted due to COPD  O2 Saturation of 97% at
 Exposure to second-hand room air
 smoke and firewood  Fine crackles
smoke auscultated at left upper
 Exertional Dyspnea for lung field
the last 3 months  Expiratory wheezes on
both lung fields

Primary Clinical Diagnosis: Chronic Obstructive Pulmonary Disease in Acute

Exacerbation

Secondary Clinical Diagnosis: Bronchial Asthma in Acute Exacerbation

Chronic Obstructive Pulmonary Disease is a common, preventable, respiratory

disease characterized by persistent airflow limitation and respiratory symptoms of

dyspnea, cough and sputum production. It is due to airway and/or alveolar

abnormalities caused by exposure to certain particles or gases.

Currently, it is the 4th leading cause of death around the world and is the 7th in the

Philippines. Risk factors include cigarette smoking, indoor air pollution (ex. Using

coal or firewood for cooking), occupational exposure to chemical fumes, outdoor air

pollution, genetic factors, old age, female sex, poor socioeconomic status, asthma and

airway hyper-reactivity, chronic bronchitis and respiratory infections.

On clinical history, symptoms include cough, sputum production and exertional

dyspnea which are usually chronic in nature. Although many patients will present

acutely, careful history will reveal that symptoms have been intermittent but are

progressively worsening over the last few months.

Physical Examination during the early stages of the disease is usually normal.

However, in a more severe condition, there is prolonged expiratory phase and may

include expiratory wheezing. In addition, signs of hyperinflation include a barrel

chest and enlarged lung volumes with poor diaphragmatic excursion as assessed by
percussion. Patients may also assume a tripod position to facilitate breathing.

Patients with predominant emphysema, traditionally termed as the “pink puffers”,

are usually thin, non-cyanotic at rest, and use accessory muscles for breathing. On

the other hand, those with predominant chronic bronchitis, or the “blue bloaters” are

heavy and cyanotic. However, it should be noted that not all patients will present as

either of these, and that these descriptions are not reliable to differentiate the two.

Very severe disease maybe accompanied by cachexia, weight loss and bitemporal

wasting.

Bronchial Asthma has similar typical symptoms of dyspnea, cough and chest

tightness, with physical findings of expiratory wheezes or rhonchi on auscultation.,

which are worse at night or early morning. But unlike COPD, signs and symptoms of

BA demonstrate reversibility and variability. Reversibility refers the rapid

improvement of FEV1within minutes after inhalation of a rapid-acting

bronchodilator or more sustained improvement after days of controller treatment.

Variability means that symptoms or pulmonary function are improving or

deteriorating over time.

For this patient, we have arrived at COPD as the primary diagnosis because her

risk factors include being an elderly female, with exposure to second-hand smoke

and firewood smoke. Her symptoms include exertional dyspnea for 3 months, cough,

and sputum production. On P.E, she was seen in mild respiratory distress, seated on

a tripod position, tachypneic, with crackles and expiratory wheezes on auscultation.

Although she is also a known asthmatic, and that this could be bronchial asthma in

acute exacerbation, it was noted that there was no reversibility when she was initially
 treated with 3 nebules of Salbutamol+Ipratropium which is essentially a rapid-acting

bronchodilator.

II. Paraclinical Diagnostic Procedure

The primary and secondary diagnosis for this case are Chronic Obstructive

Pulmonary Disease in Acute Exacerbation and Bronchial Asthma in Acute

Exacerbation, respectively. According to the Global Initiative Chronic Obstructive

Lung Disease (GOLD), Spirometry is required to make the diagnosis of COPD. A

post-bronchodilator FEV1/FVC (Forced expiratory volume in 1 second/Forced vital

capacity) <0.70 confirms the diagnosis of persistent airflow limitation. FEV1,

FEV1/FVC and all other measures for expiratory airflow are reduced. Total Lung

Capacity, Functional Residual Capacity and Residual Volume are increased,

indicating increased air tapping. Also, Spirometry can be used to rule-in or rule-out

Bronchial Asthma through the Positive Bronchodilator Reversibility test. Here, a

bronchodilator, such as albuterol, is given 10-15 minutes before measuring the FEV1.

For it to be positive, the FEV1 should have a >12% and >200 mL increase from the

baseline. This documents the variability and reversibility of the symptoms.

Other paraclinicals that can be utilized for this case are Chest X-ray, to exclude

other differential diagnoses and to show hyperinflation and low, flattened

diaphragms.

Arterial blood gases can also be done to check for resting or exertional

hypoxemia. They provide additional information on alveolar ventilation and acid-base

status.
 Procedure Benefit Risk Cost Availability
Spirometry Most None >500 pesos Available
reproducible
and objective
measurement
for airflow
limitation
Arterial Blood Provides Bleeding, >500 pesos Available
Gases information on Infection
hypoxemia,
alveolar
ventilation and
acid-base
balance

The patient in this case had chest Xray, which showed widened intercostal spaces

and flattened diaphragm. His arterial blood gases reveal hypoxemia with respiratory

acidosis. Spirometry was not done.

III. Treatment

The pretreatment primary and secondary diagnoses are COPD in acute

exacerbation and Bronchial Asthma in acute exacerbation, respectively. The goals of

treatment for COPD are to 1. Reduce symptoms; 2. Reduce frequency and severity of

exacerbations and 3. Improve exercise tolerance and health status.

Among the drugs given are bronchodilators, antimuscarinic drugs, combination

bronchodilators, and steroids.

MEDICATIONS BENEFITS RISKS EXAMPLES

Beta2 Agonists Alters airways Cardiac rhythm Short-Acting:
smooth muscle disturbances Salbutamol,
tone improving Terbutaline
emptying of the Long-Acting:
lungs Salmeterol
Antimuscarinics Blocks Drying of oral Short-Acting
acetylcholine’s mucus Ipratropium
effect on membranes bromide
 muscarinic Long-Acting:
receptors; Tiotropium
imrproves
symptoms and
reduces
exacerbations
Methylxanthines Improves FEV1 Tachycardia and Theophylline
and breathlessness arrhythmia
when added to
salmeterol
Inhaled Reduces Hoarseness, Fluticasone
Corticosteroids inflammation increased risk for
fungal infections
PDE-4 Inhibitors Improves lung Anorexia, Weight Roflumilast
function and loss, diarrhea,
reduces headache
exacerbations
Oxygen therapy Decreases Excessive oxygen
mortality rates in therapy not
COPD indicated

For stable COPD, surgical interventions are available. These are

 Lung Volume Reduction Surgery: part of the lungs are resected to reduce

hyperinflation, making respiratory muscles more effective pressure

generators.

 Lung Transplant

For this patient, we decided that she should receive non-operative

therapy, which include pharmacologic treatment. Evaluation is

made through reviewing the symptoms post-initial treatment,

assessing inhaler technique and doing the appropriate adjustment

on drugs. As a rule, if response to initial treatment is appropriate,

maintain it. If not, consider other combinations of treatment.

IV. Prevention and Health Promotion

The final diagnosis for this patient is COPD in AE. For its prevention and health

education, emphasis is given on the following concepts:

 Smoking Cessation: which has the biggest impact in the natural history of

COPD. It not only serves a part of the treatment plan but also as a

preventive measure for exacerbations and risk prevention for those around

the patient.

 Inhaler technique must be re-assessed regularly.

 Influenza and pneumococcal vaccinations decreases the incidence of

respiratory tract infections, hence minimizes the risk for more

exacerbations.

 Prophylactic antibiotic therapy of azithromycin or erythromycin are shown

to reduce exacerbations over 1 year.

 Pulmonary Rehabilitation, which includes exercise training, education and

self-management intervention can help improve dyspnea and health status.

V. References
 Jameson, J. L., Kasper, D. L., Longo, D. L., & Fauci, A. S. (2018). Harrison’s

Principles of Internal Medicine (20th ed.). New York: McGraw Hill

Education

 Global Initiative for Chronic Obstructive Lung Disease (GOLD): Pocket

Guide to COPD Diagnosis, Management and Prevention 2019 Guidelines