Cse study COPD
Name: Mr. Ahmed Hassan
Age: 58 years
Sex: Male
Marital status: Married
Occupation: Retired teacher
Admission date: 14/10/2025
Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Admitting unit: Medical Ward
Consultant: Dr. Samir Yousse
Present Illness
Mr. Ahmed Hassan, a 58-year-old male, arrived at the Emergency Department complaining of shortness
of breath, productive cough with yellow sputum, and wheezing that worsened over the past three days.
On arrival, he looked tired, anxious, and dyspneic, sitting upright and unable to speak full sentences. The
nurse noted cyanosis around the lips and use of accessory muscles for breathing.
Initial Vital Signs (at 9:00 AM):
Temperature: 37.9°C
Pulse: 108 bpm
Respiratory rate: 30 breaths/min
Blood pressure: 140/88 mmHg
SpO₂: 86% on room air
Immediate Nursing Actions:
The nurse placed the patient in high Fowler’s position to ease breathing.
Administered oxygen via nasal cannula at 2 L/min.
Checked airway patency and started nebulization with Salbutamol 2.5 mg as prescribed.
Monitored vital signs and informed the physician about the patient’s condition.
Established IV access for medications and fluids.
Collected blood samples for CBC and ABG tests.
Provided reassurance to reduce anxiety and instructed on pursed-lip breathing.
Vital Signs After 2 Hours (at 11:00 AM):
Temperature: 37.6°C
Pulse: 96 bpm
Respiratory rate: 24 breaths/min
Blood pressure: 132/84 mmHg
SpO₂: 93% on oxygen 2 L/min
The patient appeared more comfortable, with reduced wheezing and improved oxygen saturation, and
was then transferred to the medical ward for further management..
Current Medications
1. Salbutamol (Ventolin) 2.5 mg via nebulizer every 6 hours
2. Prednisolone 40 mg PO once daily (morning)
3. Ceftriaxone 1 g IV every 12 hours
4. Oxygen therapy 2 L/min via nasal cannula continuously
5. Paracetamol 1 g IV every 8 hours (if fever present)
Relevant Investigations
Test
SpO₂ 88% on room air
Respiratory Rate 28 breaths/min
Chest X-ray Hyperinflated lungs, increased bronchial marking
CBC WBC 13,000/mm³
ABG pH 7.32, PaCO₂ 55 mmHg, PaO₂ 60 mmHg pH 7.35–7.45
Physical Assessment (Head to Toe)
General appearance Alert but anxious; sitting in high Fowler’s position; dyspneic; lips slightly
cyanotic; using accessory muscles.
Head & face No trauma or lesions; facial expression tense due to difficulty breathing.
Eyes Conjunctiva pale; no jaundice; pupils equal and reactive to light.
Ears, nose, throat Nasal flaring present; mucosa moist; throat clear; no tonsillar enlargement.
Neck No lymph node enlargement; trachea midline; jugular veins not distended.
Chest (inspection) Barrel-shaped chest; symmetrical movement but reduced chest expansion.
Respiratory (palpation, percussion, auscultation) Tactile fremitus decreased bilaterally;
percussion hyperresonant; auscultation reveals wheezes and coarse crackles in both lung bases.
Cardiovascular Pulse 98 bpm, regular; BP 135/85 mmHg; heart sounds normal, no murmurs.
Abdomen Soft, non-tender; bowel sounds present; no organomegaly.
Extremities Mild finger clubbing; no edema; capillary refill <3 seconds.
Skin Warm, slightly diaphoretic; cyanosis around lips and fingertips.
Neurological Alert, oriented to time and place; no focal deficits.
