John Doe, a 58-year-old forklift operator was admitted to Grace Sloan

Question Answered step-by-step John Doe, a 58-year-old forklift operator was admitted to Grace SloanMemorial Hospital due to newly diagnosed chronic obstructive pulmonary disease. He had hypertension for the past one year and is taking Losartan 50mg once a day. He is also a chronic smoker for the past 30 years who smokes about 15 sticks of cigarettes a day. No remarkable family history other than his siblings having hypertension. He stopped drinking alcohol 15 years ago. John Doe presented with shortness of breath which progressively increased in severity for the past 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory tract infection.He has been having intermittent chronic cough associated with mucoid sputum for the past 3 years. He has also been having persistent breathlessness for the past 1 year especially on exertion. He has not sought treatment prior to this admission.On physical examination, he was tachypneic with a respiratory rate of 28 breaths per minute. There was no cyanosis. Investigations done include chest plain radiograph which showed a hyper inflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No P pulmonale indicative of right atrial hypertrophy seen.A working diagnosis of acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection was made.He was given nebulization of ipratropium bromide, salbutamol and normal saline for 2 times. His symptoms improved after being given the nebulization. He was discharged after three days when the dyspnoea had resolved. He was given metered dose inhaler of Ipratropium Bromide 40mcgs three times a day and MDI salbutamol 200mcg as needed. He was given an appointment to assess his symptoms at the outpatient department in one month time.His laboratory data is stated below:Complete Blood CountWhite cell count: 7.91 X 109/LRed blood cell: 4.48 X 1012/LHemoglobin: 133.00 g/dlHematocrit: 42.00 ratioMean cell volume: 93.80 fLMean cell hemoglobin: 29.70 pgMean cell hemoglobin conc: 317.00 g/lPlatelets: 141.00 X 109/LDifferential countNeutrophils: 60.10% 4.76 X 109/LLymphocytes: 25.30% 2.00 X 109/LMonocytes: 13.80% 1.09 X 109/LEosinophils: 0.50% 0.04 X 109/LBasophils: 0.30% 0.02 X 109/LPlain chest radiographResults: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No other abnormalities seen.Blood urea serum electrolytes and creatinineResults:Urea : 3.7mmol/LSodium : 135 mmol/LPotassium : 3.7 mmol/LCreatinine : 65 umol/LElectrocardiogramResults: ECG with sinus rhythm. There is no P pulmonale seen. There is low voltage seen. No ischaemic changes seen. No left ventricular hypertrophy.Interpretation: Normal ECG with low voltage is seen in a hyperinflated chest such as in patients with COPDCase Assessment Form1. General Information at Time of Admission/Interview2. Summarize the case scenario given to 3. Subjective and Objective Information4. Chief complaint5. Other signs and symptoms6. History of Present Illness7. Patient’s family HistoryA. Patient’s Social HistoryB. Medication HistoryC. Physical Examination8. Laboratory Results9. Treatment Given10.Assessment/Clinical NotesBriefly discuss the diagnosis and the treatment given to the patient.As a part of the healthcare team list medical advices that you can give to the patient. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)