Case Report

Acute Exacerbation of
Chronic Obstructive Pulmonary Disease

Fitri Afifah Nurullah, MD

Patient Identity

Name : Mr. S
Sex : Male
Age : 76 yo
Address : Gunungjati
Date of Admission : 4 January 2018
Health Insurance : BPJS
Medical Record : 16030XXX
Doctor on Duty : dr. Edy Sp.P
 Chief Complain
Shortness of Breath
 History of Present Illness

Mr. S, 76 year old man, presented to RSPC ER with

shortness of breath which was progressively increased in
severity for past 3 days associated with noisy breathing. He was
breathless even at rest but was still able to speak in sentences.
History of Present Illness

Mr. S then developed symptoms such as rhinorrhea and

sore throat one week prior to admission. He said his cough
started to develop into productive cough which was increased
sputum purulence and volume in 5 days ago and also followed
by sudden onset of fever.
History of Present Illness

Mr. noticed that his symptoms had insidious onset. He

has been having intermittent chronic cough associated with
sputum for the past 3 years. He has also been having persistent
breathlessness for the past 1 year especially on exertion.
Few hours prior to admission, Mr. S couldn’t anymore
tolerate his complain, shortness of breath. He has not sought
treatment prior to this admission.
 History of Present Illness

He denied any history of trauma, chest pain, aching

during inspiration or expirations, night sweat, bloody sputum
cough or blood streak sputum, weight loss, appetite loss, using
multiple pillows while sleeping, swollen feet, fatigue, shortness
of breath worsening by activities and changing of mental
status. He also did not notice any blueness around his lips or at
his fingers.
Past Medical History

It was his second time being hospitalized after ongoing an

operation of benign prostatic hyperplasia 2 years ago. He
denied any history of asthma, allergic reaction to drugs, food,
pollens or weather. He denied any history of hypertension,
heart disease and chronic kidney disease.
Social & Environmental History

Mr. S, once was a long-vehicle driver, he started smoking

since 65 years ago, since that time he kept smoking 2 packs of
non-filtered cigarette per day. There’s nobody in his family
diagnosed suffering lung disease. He was living in an
overpopulated house with 9 other people. His house was not
well air-circulated, it didn’t have enough ventilation, he
admitted.
Familial Background
Family Genogram
Physical Examination
General Examinations & Vital Signs

Consciousness Vital Signs

Composmentis
Pulse rate : 115 beats/min
equal and regular
Appearance Respiratory rate : 29 breaths/min
Mr. S was well nourished and Body Temperature : 38.2oC
alert but looked gasping for Blood Pressure : 140/90
breath. He was able to speak in Oxygen Saturation : 91% on free air
sentences.
Head to Toe Examination
Head

• Normal shape, symmetrical, no signs of trauma

Eyes

• pupil were round, equal and reactive to light, eye movement were
normal, there’s no sign of anemic conjunctiva or icteric sclera.

ENT

• Ear Shape and position were normal, external auditory canals were
clear without discharge, redness, lesion, mass or tenderness.
• Nares were clear without septum deviation and foreign body. No nasal
flaring. Pursed lip breathing was noted
• Oropharynx was clear
Head to Toe Examination

Mouth
• Mouth : mucous membrane were moist, without any sign of
perioral cyanosis.

Neck
• Lymph nodes were not palpable, The jugular venous pressure is
mildly elevated at 3.5 cm above the sternal angle.
Head to Toe Examination
Thorax Examination

Lung Heart
• The chest moves equally during respirations. Using
of accessory muscles, intercostal, subcostal and • Apex beat could not be seen or even
suprasternal retraction was seen. There are no palpable.
chest wall deformities. Intercostal spaces were • Heart was below normal size on
widened. percussion.
• On palpation, chest expansion was reduced both • First and second heart sounds were
sides. Tactile fremitus was equal on both sides.
heard without any murmur and
• Both Lungs were sounded resonant on percussion. gallops.
• On auscultation vesicular breathing is heard.
Wheezing is generalized heard. Crackles were
heard over lower lobes of lungs on auscultation.
Head to Toe Examination
Abdomen

• There was no mass or tenderness on palpation, positive bowel

sounds on auscultation.

Extremities

• Extremities were warm on palpation, there was no peripheral

cyanosis, deformities, clubbing nails, muscle wasting, palmar
erythema, flapping tremor or edema seen. Capillary refill time was
less than 2 seconds.

Genital

• Genital area was intact without any lesion, mass or erythema.

Assessment and Plan
Differential Diagnosis

ICD 10 Code

Dyspnea due to
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J45.41 Moderate persistent asthma with (acute) exacerbation
I50 Heart failure
J18.9 Pneumonia, unspecified organism
J47 Bronchiectasis
A15.0 Tuberculosis of Lung
 Further Investigation
• Laboratory Study
• Routine blood count (done)
• Blood Gas Analysis (not done)
• Plain Chest Radiograph (done)
• ECG (done)
Laboratory Study

Routine Blood Count

Result Normal Value
Hb 11.9 g/dL 13-16
Ht 37 % 40-48
L 16.900 cells/μL 3.5-10
Tr 199.000 cells/μ 150-400
Plain Chest
Radiograph
ECG
Working Diagnosis

1. J44.1 Chronic obstructive pulmonary disease with

(acute) exacerbation
2. I50 Heart failure
Acute Management
Airway
Drugs
• Clear
• Nebulization of Salbutamol with Normal
Breathing Saline every 8 hours until
breathlessness decreases.
• Supplemental oxygen via nasal prong • IV methylprednisolone 125mg twice
3L/min daily for 10 days.
• Maintain SpO2 above 90%. • IV antibiotic, levofloxacin 750mg once
daily for 5 days.
• IV Paracetamol 500mg three times daily
Circulation (if needed)
• Stabilize IV line with RL 2000cc/day. • Oral N-Acetyl cysteine three times daily

Close monitoring of vital signs and SpO2 hourly until the patient's breathlessness improves,
close monitoring if patient deteriorates such as increased respiratory rate or drop in oxygen saturation below 92%.
Acute Management (cont.)

Education

•Explaining about disease and risk factors

•Lifestyle modification
•Counseling for smoking cessation
•Follow up and long-term therapy
 In Ward Management
1. Supplemental O2 3lpm
2. IV line, Ringer Lactate 20drops/min (2000cc/day)
3. N-asetylsistein 3x1 tab/day
4. Nebulization of salbutamol 1x1 amp/8hrs
5. Paracetamol 3x1fl/day (if needed)
6. Levofloxacin 1x750mg/day IV
7. Methylprednisolone 2x125mg/day IV
8. Observation of vital signs every 3 hrs
 05-01-2018 06-01-2018

• S : Shortness of breath, productive • S : Shortness of breath improved,

cough, fever (-) productive cough, fever (-)
•O: • O:
• CM BP130/90, RR24, • CM BP120/80
• PR:80, S:37,5, SpO2 96%
• PR:76, S:37,1 RR24, SpO2 98%
• thorax: wheezing+/+
• A : AECOPD • thorax: wheezing-/-

Follow Up
• P: • A : AECOPD
• O2 3 lpm • P:
• Nebulization of Salbutamol & NS every • O2 3 lpm
8hrs • IV Levofloxacin 470mg once daily
• IV Levofloxacin 470mg once daily
• IV Methylprednisolone 125mg
• IV Methylprednisolone 125mg twice
twice daily
daily
• Oral N-acetyl cysteine 3x/day • Oral N-acetyl cysteine 3x/day
• Nebulization of Salbutamol & NS
(if needed)
 Discharging Management
• Pharmacological
• Levofloxacin 500mg once daily
• Methylprednisolone 125mg twice daily
• N-acetyl cysteine three times a day
• Non Pharmacological
• Smoking cessation
• Routine check up
• Preventing other risk factors
PROGNOSIS
Quo Ad Vitam : dubia ad malam
Quo Ad Functionam : dubia ad malam
Quo Ad Sanationam : ad malam
Thank You