64 year old male with COPD with acute exacerbation

By: Jrameel T. Bascara

 Demographic Data Name: J.C. Birthday: 1/25/1948 Address: 136 kamias road, kamias QC Religion: Christian Civil Status: Married Date of Admission: August 25, 2012 Diagnosis: COPD with acute exacerbation

 Chief Complaint: Difficulty of breathing Present history of Illness: Patient is known hypertensive since 2010 and maintained on amlodipine 5m/ 1tab, 1 tab OD, but physician discontinued the meds since the blood pressure is stable. Not known diabetic and asthmatic. Has COPD for 10 years with the following medications ancimar 1 tab OD, combuvent neb, spinva and seretide. Present illness started 1 week PTA, patient experienced difficulty of breathing with east fatigue ability, orthopnea, chest pain and fever, no consultation was done re nebulized but with temporary relief.

 1 day PTA patient still had the above signs and symptoms noted now with severe difficulty of breathing. He sought at lung center, assessed and was prescribed medication and was sent home few hours PTA. Patient still have difficulty of breathing which prompted consultation on this institute hence his admission. Past Medical: Non diabetic, non-asthmatic, (+) history of PTB 15 years ago with two computed treatment, (-) previous history of operation and accidents. No known allergies. Family History: (+) cervical CA on mother, on his mother side (+) hypertension and (-) DM, for his social he stopped smoking and drinking alcohol for 10 years.

 Physical Assessment: Vital Signs: Temp: 36.70C RR: 26 HR: 108 BP: 110/70 General appearance: -The height of the client is 167cm, weight is 52.2kg indicates normal BMI=19.1, body built is small frame, grooming and hygiene is good, odor is good, and there are no obvious physical deformities.

 Mental Status: -The client is conscious; oriented to time, place, and date. Skin: -The skin color is brown, extremities; the texture of the skin is dry, both hands and feet are warm to touch; hair distribution is even; skin turgor and capillary refill is two seconds. Head: -Head is proportion to the body. The scalp is non-tender. The hair is thin, the color is white, hair is evenly distributed, hair is shiny and smooth, and no palpated lesions and visible masses. Facial movements are symmetrical.

 Eye: -Palpebral conjunctiva is pink, the cornea is clear, (+) corneal sensitivity, black pupils, pupils are equally (3mm) reactive to light and accommodation, (+) peripheral visual fields, the patient is wearing correctional glasses. The sclera is anicteric. The eyebrow and eyelashes are thin. Eyelids are symmetrical. Ears: -Ears are symmetrical; there are no visible mass and lesions, auricles are non-tender, (+) serumen on both ears.

 Nose: -There is discharge in the two nares. Septum is in midline, pink mucosa, nasolabial folds are symmetrical. The frontal and maxillary sinuses are tender. NGT tube is inserted in right nares. Mouth and Pharynx: -Upper and lower lips are dry and pink, no visible masses or lesions, (+) dental carries, (+) tongue movement, and uvula is in the midline. Oral mucosa is dry and color pink, hard and soft palate is color pink. Endotracheal tube is inserted.

 Neck: - (+) sternocleidomastoid and trapezius muscles movement; there are enlargement of lymph nodes, and nontender thyroid gland. Trachea is in midline. Chest/ Lungs: -The size of the posterior and lateral thorax is equal and wheezing breath sounds heard upon auscultation at the chest. The RR of the patient is 26. Breathing pattern is tachypnea.

 Breast: -The breast is flat, he has darker color of areolas and nipples, nipples are everted, lymph nodes are not palpable and nontender. Heart: -Heart Rate is 108 beats per minute; the apical pulse is located at the 5th intercostal, mid-clavicular line; and there is no presence of jugular distention.

 Abdomen: -The shape of the abdomen is flat, non-tender upon palpation, (-) muscle guarding, 15 bowel sounds per minute, tympanic upon percussion, (-) rashes and lesions, non-palpable bladder. Genitals: - There are no bulges or scars in the inguinal region. The patient is circumcised. Foley catheter is inserted. Extremities: -Upper and lower extremities of the patient are symmetrical, can perform ROM. No edemas on extremities, temperature on upper and lower extremities are warm.

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Pathophysiology

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