COPD presentation.

1. CASE PRESENTATION

2. Age:60yrs sex: Male
Wt : 47 kg unit: Med-I
REASON FOR ADMISSION
C/o Fever ( not associated with chills/ rigors) x 20
days
C/o Breathlessness x 10 days
C/o Productive cough x 20 days
SHx: Chronic smoker since 35 yrs ( 1 bundle per
day).. pack year- 10.5
PMx: KCO COPD Since 7 yrs
Allergies : Nil

3. Provisional diagnosis
Acute exacerbation of COPD and
fever for evaluation

4. Day 1
O/E BP:125/80mmHg
Pulse : 84 Bpm
Advice :
CBC, WIDAL TEST, CHEST X RAY, AFB,
UREA, SeCr , Ser electrolytes,
O2Saturation – 65 %

5. Day 1
Rx
Oxygen inhalation 4 lt/min
Neb budesonide 100mcg Q6H
Neb salbutamol 200mcg Q6H
Inj ceftriaxone 1gm iv 1-0-1
T paracetamol 650mg po 1-0-1

6. Day 2
O/E BP:120/80mmHg
Patient c/o chest pain Pulse:80 Bpm
Cxray :Emphysematous lung Temp:100o
F
Hb: 13.1g%
WBC: 12,OOOcell/cumm
N:60% Widal: negative
E :12% Malarial parasite :negative
B :00% AFB : NEGATIVE
L :26%
M :02%
ESR: 80mm/hr
O2Saturation – 90 %
RX
Patient was advised to continue same treatment

7. Day 3 & 4
O/E General condition was stable BP : 120/80
Patient was afebrile PULSE: 80 Bpm
Rx
ADVISED TO STOP
Tab Paracetamol
Oxygen inhalation

8. 4th
,5th
day same
• 5th
day patient discharged
Inhaler ipratropium + salbutamol 6th
hrly
Inhaler budesonide 8th
hrly