Question

Case Presentation

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 phelgm

 _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 edemae

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

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

Discussion Question:

Provide a detailed rationale for the abnormal vital signs noted in your patient on physical examination

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Provide a detailed rationale for the abnormal vital signs noted in your patient on physical examination

Answer 1

• Patient is a known case of dyspnoea keeping that in mind lets discuss about the abnormal vital signs
• Blood pressure is quite high and hypertension occurs due to trouble in right side of the heart to push the blood flow through the lungs due to shortness of breath.
• Pulse is primarily high because of the high bp and shortness of breath, secondarily due to history of smoking habit too
• Respiratory rate is high because of shortness in one respiration. And also due to the hyperinflated lungs and flattened diaphragm
• Since examined in room, temperature and saturation you can consider as normal