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COPD Case Study Adapted from Lewis VCE Lesson 11, Emphysema & Pneumonia.pdf
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1COPD Case Study Adapted from Lewis VCE Lesson 11, Emphysema & Pneumonia
Patricia Newman, 61 admitted with dyspnea at rest, cough, and fever
Smoker x 45 years; 2ppd
Multiple hospitalizations for pneumonia in past 2 years
Osteoporosis x 8 years
HTN x 15 years
Divorced x 15 years; 2 adult children live out of state
Mother d at 63 of MI; father d at 59 of stroke
Medications at Home:
Calcium carbonate 600 mg 4 times per day
Estrogen patch twice a week
Chlorothiazide 500 mg daily
Atenolol 50 mg daily
Sleeps on 2 pillows at night
Emphysema for 12 years
Frequent cough productive of moderate amount of yellow sputum
Short of breath when walking 20 feet
HTN well controlled on meds; no other known cardiovascular problem
Objective:
T – 101.1; B/P – 162/90; R – 26, regular, slightly labored; P – 108, regular
O2 sat 89% on room air
Lungs – coarse crackles throughout lungs; using accessory muscles to breathe
Mental status – alert oriented to person, place, time; cranial nerves intact; PERRLA
Abomen flat, nontender; bowel sounds active; pulse 2+ all extremities
Q1 Which of the clinical manifestations are abnormal and why? What would normal findings be?
High temperature, high pulse, high respirations, low O2 saturations, crackles are also abnormal, accessory
muscles, labored reparations because they are all out of normal ranges, some of the normal findings would be
a 2+ pulse, flat nontender abdomen, and active bowel sounds. Normal vital signs, being able to walk 20 feet
Chest x-ray – right middle and upper lobe infiltrates, consistent with pneumonia; hyperinflation consistent with
emphysema
WBC 16,000
RBC 4.9
Hgb 15
Hct 45
MCV 90
Platelets 250,000
Glucose 78
Na- 140
Page 1 of 6
, 2
K+ 3.2
Cl- 101
Creatinine 0.8
Page 2 of 6
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