Cold or Flu-like symptoms

Cold or flu-like symptoms. Miguel is a 63-year male patient who presented to the emergency department complaining of a week history of progressive dyspnea, wheezing and productive cough with whitish phlegm. He denies any recent cold or flu-like symptoms. Miguel also denies any fever or chills. He has been using his Ventolin MDI but symptoms are worsening. On assessment, you noted that the client developed severe dyspnea with exertion. He was assuming a tripod position and became pale and diaphoretic with movement. He presented with 2-3 word dyspnea.

Past Medical History

· Diagnosed with COPD for 8 years

· Hypertension

· Smokes cigarette 1.5 pack/day for 25 years

· Reduce to about 5 cigarettes per day

 Medications 

· Salbutamol MDI 4 inhalations every 4-8 hours PRN

· Ipatropium bromide MDI 2 inhalations QID

Physical examination findings

Vital Signs

Blood pressure 178/90

Pulse 110

Respirations 36 laboured & shallow

Temperature 36.2 0C

SaO2 80% on room air

Skin & mucous membranes

· diaphoretic

· Cool & clammy to touch Respiratory

· 2-3 words dyspnea

· Use of accessory muscles at rest

· “Barrel chest” appearance

· Poor breath sounds bilaterally

· Productive cough with whitish phlegm

· Purse lip breathing with prolonged expiration

Cardiovascular

· Heart sounds are normal

· tachycardia Extremities · peripheral pulses 2+ bilaterally in all extremities

· clubbing · cyanotic nail beds

· +2 bilateral pitting edema

Gastrointestinal 

· no nausea & vomiting

· abdominal distention

· anorexia & weight loss

Laboratory Results

Tests                            Results                            Normal value

White blood cell count 11.0 × 109 /L               4.0-10.0 × 109 /L

Reb blood cell           6.4 X 1012/L                  4.0 – 5.2 X 1012/L

Serum sodium            148 mmol/L                  135-145 mmol/L

Serum chloride           110 mmol/L                  98 – 106 mmol/L

Serum potassium           3.8 mmol/L                     3.5-5.0 mmol/L

Blood urea nitrogen (BUN)  7.0 mmol/L                 2.5-8.0 mmol/L

Serum Creatinine             100 μmol/L                      70 – 120 μmol/L

Chest X-ray

· hyperinflated lungs with a flattened diaphragm

· large anterior posterior diameter Pulmonary Function Tests (PFTs)

· increased residual volume and total lung capacity

· decreased forced expiratory volume and vital capacity.

Diagnosis

Miguel was diagnosed with acute COPD exacerbation. He was ordered the following medications:

· salbutamol (Ventolin®) 5 mg q1hr PRN by nebulizer

· Ipatropium bromide (Atrovent®) 500 mcg by nebulizer PRN (max. 3 doses)

· Prednisone 50 mg po X 3 days

1. What are some risk factors for the development of COPD? What is the single most risk factor for the development of COPD in Miguel?

2. The patient’s chest x-ray reported hyperinflated lungs with a flattened diaphragm. Explain the pathophysiology for this finding in the patient.