FACULTY OF MEDICINE

DEPARTMENT OF INTERNAL
MEDICINE
CLINICAL CASES WRITE UP

NAME : MUHAMMAD ARIFF BIN MAHDZUB

MATRIC NO : MBBS 0913036
I/C NO : 920815-01-5361
YEAR : YEAR 3 (Group B1)
SUPERVISOR : Dr Syed Naquib/ Dato Dr Sapari Satwi

IDENTIFICATION DATA
Name : Embong putih
Age : 63 years old
Gender: Male
Ethnicity : Malay
Marital status : Married
Occupation : Shopkeeper
Registration no (R/N) : 937319
Ward : Orkid 8B
Date of admission : 20th May2015
Date of clerking : 21th May 2015
History taken from : Patient

HISTORY
CHIEF COMPLAINT
En Embong Putih, 63 years old Malay gentleman,with underlying chronic
obstructive pulmonary disease (COPD), hypertension and hyperlipidemia 10
years ago and shortness of breath for 2 days duration prior to admission.
History of presenting illness
He was apparently well until 5 days prior to admission, he started to develop
intermittent cough. The cough was productive with whitish and yellowish
sputum. It just about 1 table spoon and there was no blood in the sputum. He
also denied any frothy pink colour sputum. He took cough depressant to
relieve the cough however its effect just temporary. It became worsen and
persistent 2 days prior of admission.
It was also associated with shortness of breath 2 days prior to admission. The
shortness of breath at first occur intermittently and with activity such as
walking to toilet at proximate distance of 15 metres. It was associated with
noisy breathing. He unable to speak in a full sentences due to shortness of
breath. He need to use meter dose inhaler prescribed to him to relieve the
shortness of breath. However, on the day admission, the shortness of breath
become worsen and persistent to the extend he developed shortness of
breath at rest. It was also no longer relieve by meter dose inhaler prescribe
to him.
Furthermore, the shortness of breath cause him to unable to lie flat for sleep.
It was also associated with sudden wake up at night due to shortness of
breath. He wake up 3 to 4 times throughout night gasping for air.
Otherwise, there was no upper respiratory symptoms such as sore throat,
runny nose,and fever. However, he denied any night sweat and had any
contact with TB patients. He also denied any constitutional symptom such
as loss of weight, low of appetite, and lethargy.
Further questioning, this is the second admission for this years which the last
admission 4 months ago. Previously, he had been hospitalized only once in a
years. However, the symptoms progressively worse over years as he unable
to do his works as fisherman. His last attack was 10 days prior to admission.
However, the symptom relieve after took medication and did not require
hospital admission.

Systemic reviews
General : patient denied of
appetite

having fever, recent loss of weight or loss of

Cardiovascular systems : patient denied of having dyspnea, chest pain and

palpitation .
Respiratory systems : apart from cough with sputum, the patient did not
experience hemoptysis, night sweat, or sore throat
Genitourinary systems : patient claimed that there was no oliguria, dysuria,
hematuria, polyuria, hesitancy, loin pain, discharge and no nocturia.
Neurological system : patient had no history of loss of consciousness,
headache, weakness and seizure, numbness and poor vision
Gastro-intestinal : patient denied of nausea, vomiting, abdominal pain,
diarrhea, constipation, haematomesis and maleana.
Skin : patient do not experienced any rash, ulcer and pruritis.
Heamatological systems : there was no purpura, epistaxis, gum bleeding.
Musculo-skeletal system : patient denied of muscle cramp, joint pain, joint
swelling and stiffness.

Past medical,surgical and drug history

He had been diagnosed with COPD 10 years ago when he presented with
worsening shortness of breath associated with cough. He was given MDI
Salbutamol and his last admission to the hospital was 4 month ago due to
worsening shortness of breath and cough.
He also had hypertension and hyperlipidemia accidentally diagnosed 10
years ago during his first admission due to cough and shortness of breath.
He was on medication such as Perindopril 4mg OD and Simvastatin 40mg
ON. He was said to be compliant to the medication. He was under follow up
at MOPD 3 monthly and compliant to his follow up. Blood pressure was
controlled with range of (120- 130/90-94) during follow up. There was no
history of stroke, intermittent claudication, blurring of vision and chest pain.

Besides taking the drugs prescribed to him, the patient denied taking any
over the counter or traditional drug. He had no allergy to drug.
Patient never undergone any sugery before.

Family history
Father, died at age
60 due to unknown
cause

brother

sister

Mother, died at the

of 78 due to
unknown cause

brother

himself

He is the youngest in the siblings. He was unsure the health status of his
sibling. However, no history of malignancy, kidney problem and history of
hypertension running in his family.

Social and personal history

He is a shopkeeper who live in Inderamahkota, Kuantan with his wife and 7
children. The house is a single storey house with basic amenities. The toilet
is about 5 meter from his room. He is a father of 7 children and 4 of them
live outside the town. He is a non alcoholic and denied any high risk
behaviour. He is an ex- smoker with 40 packed year of cigarette. Currently he
has stop smoking for 20 years due to his shortness of breath.

Physical examination
General examination
My patient was a thin-build elderly gentleman. He was lying 45 degree in
propped up position. He was conscious and alert. He was in respiratory
distress with respiratory rate of 25 breath per minute and on nasal prong 3L.
He looks lethargy but not in pain. He is able to speak in phrases. There was
meter dose inhaler blue colour located at the side of bed. The conjunctiva
was pink, there was no jaundice noted. There was no central cyanosis.
The jugular venous pressure was not rise
On hand examination, hand was warm and non- clammy. There was flapping
tremor but no palmar erythema and no peripheral cyanosis. There was
branula attached to dorsum of left hand without infusion.
Vital signs
Blood pressure: 130/96 mmHg
Heart rate: 110 beat per minute, regular rhythm and good volume. No
bounding pulse
Temperature: 37C
Spo2: 97% under nasal prong.

Specific examination
Respiratory examination
On inspection, there was a barrel shape chest that moves symmetrically with
respiration. There was no scar and dilated vein noted. Trachea was centrally
located. Chest expension and tactile fremitus were diminised for both side.
On percussion, there were resonance sound heard, with cardic and liver
dullness. On ascultation, the air entry were diminised for both side more
prominent at lower zone. There was vesicular breath sound and generalised
rhonchi heard, more prominent at lower zone.
Cardiovascular examination
On precordium examination, there was no visible apex beat. Apex beat was
palpable at 5th intercostal space mid clavicular line . There was no thrill and

no parasternal heave. On auscultation, dual heart sound was heard with no

murmur. No loud P2 and gallop rhythm was heard.
Abdominal examination
On inspection, the abdomen not distended. The umbilicus was centrally
located. There was no scar and no dilated veins. On palpation, the abdomen
was soft and non tender. There was no hepatosplenomegaly. The traubes
space was resonance. There was no shifting dullness and fluid thrill.
Neurological examination.
On inspection of upper limb, there was no muscle wasting, abnormal posture,
scar and fasciculation. The tone, power and reflex of both upper limbs were
normal.

The

patient

did

not

have

intention

tremor,

past

pointing,

dysdiadokinesia.
On lower limbs examination, on inspection, there was no wasting, no
abnormal posture, no scar and no fasciculation. The tone, power and reflex of
both lower limbs were normal. The coordination was intact. Pain sensation
was intact and also proprioception.
All cranial nerve was intact.

SUMMARY
En Embong Putih , 63years old Malay gentleman, an ex-smoker with 40
packed years
with underlying COPD, hypertension ,hyperlipidemia,
presented with worsening productive cough with yellow sputum and
associated with shortness of breath, wheezing and 2 days prior to admission.
There was multiple history of hospital admission with the same presention.
On examination, the patient was in respiratory distress with some evidence
of hypercapnia (flapping tremor). The respiratory examination revealed
positive barrel shaped, with evidence of reduce chest expension & tactile
fremitus and reduce air entry with some evidance of generalize ronchi.
PROVISIONAL DIAGNOSIS
Acute exacerbation chronic obstructive pulmonary disease secondary
community acquired pneumonia and can came out with complication
ofrespiratory failure, pleural effusion and empyema.

Differential diagnosis
Diagnosis
Cor pulmonalae

Points for
1. Underlying COPD 5
years
2. SOB,PND,orthopnea
3. Sign of CO2 retentionflapping tremor

Points against
1. No parasternal
heave
2. No loud P2
heard

Bronchiectasis

1. Cough, sputum
2. SOB
3. Multiple recurrent
infection

1. No
hemoptysi
s
2. No
pleuritic
chest pain
1. No pleuritic
chest pain
2. Physical
examination no
evidence of
pneumothorax

Pneumothorax
secondary to
COPD

1. Shortness of breath
2. Underlying COPD

INVESTIGATIONS
1. Peak expiratory flow rate (before nebulised and after nebulised)
Result/ finding: not done on this patient
Reason to do: to asses the condition of the patient before and after
giving nebulized whether there is improve or not. If not, the medication
need to be alter in view of the patient condition. It is also can detect
airway limitation in the patient, however it was not specific.
2. Electrocardiogram

Result/ finding : heart rate : 110 beat per minute, sinus rhythm,
normal axis, no ST elevation, no ventricular hypertrophy
Reason to do:
It can detect axis deviation and hyperthropy in congestive cardiac
failure and detect the changes of ECG in advance COPD (show right
ventricular hypertrophy, right axis deviation).
3. Arterial blood gas (in emergency department)
Result:
pH
: 7.349 (acidosis)
pCO2 : 36.4 (35-45) (normal)
pO2 : 74.6 (80-100) (low)
HCO3: 19.6 (22-28) (low)
Interpretation: there is hypoxemia with normocapnia indicate patient
in respiratory failure type I and patient in state of uncompensated
metabolic acidosis

4. Full blood count

Result:
Haemoglobin : 14.8 g/dL
PCV: 47.6
Total white blood cell: 15.4
Neutrophil predominant 13.20
Interpretation: the haemoglobin level within normal range thus exclude
polycythemia that can develop in chronic hypoxemia. The leucocytosis
indicate evidence of infection with neutrophil predominant most
probably bacteria.
5. Renal function test
Result:
Urea: 5.6 (3-9.2)
Sodium : 140
Potassium: 4
Chloride: 105
Creatinine: 86
Interpretation: the creatinine & urea within normal range
6. Blood culture and sensitivity
Result: aerobic : no growth
Anaerobic : no growth
Interpretation: no bacterial growth in the sputum, thus not for bacterial
infection in the lung
7. Liver function test
Result: AST : 18 U/L
ALT : 6 U/L
ALP : 54 U/L
Interpretation : to look for liver congestion due to cor- pulmonalae and
congestive heart failure. there normal AST and ALT value.
8. Fasting lipid profile
Reason to do: to assess the hyperlipidemia disease whether the
medication is optimum for patient. Controlling the hyperlipidemia also
control the risk of complication of hypertension in this patient.

9. Plain radiograph of the chest

Result: the chest xray was taken in postero-anterior view, the

exposure and penetration were adequate. There was homogenous
opacity with air bronchogram located at left lower zone of the lung.
There was no evidence of hyperinflated lung. There is dilated right
pulmonary vessel noted. There was no cardiomegaly. No pleural line
and devoid of cardiac marking and tachea is centrally located.
However, there was no Batwing appearance, Kerley B-line and
pleural effusion.

10.

Spirometry

Reason to do: result of FEV1 and FVC are important factor to diagnose
COPD and assess its severity.
TABLE 1-3 classification of COPD Severity Based on Spirometry
Impairment and Symptoms
COPD stage

Severity

Classification by
post
bronchodilator
spirometric
values
FEV1/ FVC < 0.70
FEV1 >= 80%
PREDICTED

Mild

II

Moderate

FEV1/ FVC < 0.7

50% <= FEV1 <
80%

III

Severe

FEV1/ FVC < 0.7

30% <= FEV <
50% predicted

IV

Very severe

FEV1 / FVC < 0.7

FEV1 <30%
predicted
/ FEV < 50%

Classification by
symptoms and
disability

Shortness of
breath when
hurrying on the
level or walking
up a slight hill
Walks slower
than people of
the same age on
the level because
of
breathlessness/
stops for breath
after walking
about 100m or
after or after a
few minutes at
own pace on the
level
Too breathless to
leave the house /
breathless when
dressing and
undressing
Presence of
chronic
respiratory

predicted +
chronic
respiratory
failure

failure / clinical
signs of right
heart failure.

FEV1 = forced expiatory phase in 1 second

FVC = forced vital capacity

Management
1. Admit the patient
2. patient being resuscitated by checking the airway, breathing, and
cirulation. Airway was checked and secured as patient able to talk.
3. Adequate ventilation was ensure via monitor sPO2, oxygen supplement
was given to support his breathing. The sPO2 aim is 88-92%. Excessive
oxygen administer can lead to hypercapnic respiratory and lead to
ventilation perfusion mismatch.
Specific treatment for AECOPD secondary to pneumonia
1. bronchodilator (salbutamol 5mg/4hr and ipratropium 500ug/6hr)
2. use if evidance of infection. The antibiotic such as Iamoxicillin
500mg/8hr per oral was given.
3. Non pharmacologically, he was adviced for bed rest and put in 45
degree propped up position.

Discussion
En Embong Putih , 63years old Malay gentleman, an ex-smoker with 40
packed years
with underlying COPD, hypertension ,hyperlipidemia,
presented with worsening productive cough with yellow sputum and
associated with shortness of breath, wheezing and 2 days prior to admission.
There was multiple history of hospital admission with the same presention.
On examination, the patient was in respiratory distress with some evidence
of hypercapnia (flapping tremor). The respiratory examination revealed
positive barrel shaped, with evidence of reduce chest expension & tactile
fremitus and reduce air entry with some evidance of generalize ronchi.
Thus, the discussion will focus on AECOPD secondary to community
acquired pneumonia. COPD by definition is a chronic progressive irreversible
airway obstruction due to inflammatory response to noxious particle.
Chronic obstructive pulmonary disease (COPD) consists a variety of
clinical syndrome associated with destruction of the lungs and airflow
limitations. It is characterized by abnormalities in the lungs that make it
difficult to exhale normally. Generally, it composed of emphysema
(pathological dilatation of air spaces distal to terminal bronchioles without
obvious fibrosis) and chronic bronchitis
In diagnosing COPD, history of dyspnea, chronic cough, chronic sputum
production, exposure to noxious particle, family history of COPD and
spirometry is key indicator to consider diagnosis. Force Expiratory Flow Rate
in 1 second over force vital capacity in spirometry test less than 0.7 which
indicate airway obstruction. In this patient, the COPD diagnosis already
establish through spirometry result. The patient is an ex smoker with 40
packed year. Based on the CPG, management of COPD more than 10 packyear is enough as risk factor to develop COPD.
The pathophysiology of COPD start when there is present of irritant
such as cigerrette smoke or noxious particle cause repeated injury and repair
to proximal airway, peripheral airway, lung parenchyme and pulmonary
vasculature resulting in chronic inflammation and structural changes in that
place. The mucus secreting gland become hypertrophy, increase in number
of goblet cells in the bronchi and bronchiole and decrease in ciliated cell.
Thus, the mucosal production will be more and cannot be transport thus
obstruct the airway. This obstruction more prominent during expiration as

during inspiratory phase, the airways normally dilate whereas during

expiration phase, the airway is narrower.
Acute exacerbation of COPD often precipitated by upper respiratory
tract infection (URTI), pneumonia, pulmonary embolism, cold weather,
pollution and arrhythmia.
The patient developed shortness of breath and cough on this current
admission which are a typical presentation of acute exacerbation of COPD. In
COPD, the patient developed shortness of breath due to airway obstruction
and the cough with purulent sputum was due to mucosal edema and the
body protective mechanism to get rid the mucus from obstructing the airway.
There are some benefit of medication given, for example
bronchodilator can improve airway obstruction and reduce lung
hyperinflatation, and improve dyspnea. Corticosteroid can Improve lung
function test over the first 72 hours, shorten hospital stay and reduce
treatment failure over the subsequent 30 days. However, it should be
discontinue after acute episode to prevent side effect. Antibiotic was given to
fight common cause of AECOPD.

Reference
1. Clinical Practice Guidelines in the management of Chronic Obstructive
Pulmonary Disease, Ministry of Health Malaysia , 2015
2. http://emedicine.medscape.com/
3. Oxford Handbook of Clinical Medicine, 8th edition, by Longmore,
Wilkinson and Torok, published by Oxford University Press