COPD Case Study
Part 1
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 97.6°F, 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 past several weeks. She states that his highest weight was 135Ibs 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
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 ½ NS at 75 mL/hr
NPO
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.
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
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
Patient Care Summary Sheet
Day: 2
Temp (C)
Pulse
Respiration
BP
Intake
Oral
IV
TF
Formula/Flush
Shift Total
Output
Cath
Emesis
BM
Drains
Shift Total
Gain
Loss
Signatures
Room: 12
Nights
36.6
80
Wt YTDY: 55.5
110/80
NPO
75
-
-
-
-
-
-
400
-
Wt Today: 55.5
Days
36.5
85
Evenings
36.7
83
125/92
117/80
75
-
-
-
-
25
25
475
150
200
25
5
75
25
45
45
75
50
45
--
--
--
--
760
275
75
25
300
50
455
750
-55
Mary Rogers
-275
Linda Clark
200
125
175
75
725
+35
Jane Patten
75