65 year old malay male from tanjung keling, former army officer and a former security guard was admitted 2 days ago presenting with breathlessness for 1 day.

Breathlessness for 1 day was sudden in onset, grade 4, there is orthopnea but no pnd, and no wheezing.Patient was a heavy smoker 30 sticks a day, since the age of 18, he stopped last year following a similar episode at the month of may 2006. Patient came in for breathlessness, where by he has to undergo tracheostomy following failing in medical treatment and intubation. Patient was in the hospital for a month, and he was discharge with 2 inhalers and oral medication.

he was pronounced to have DM and HT in this admission. No chest pain, cough, sputum production or fever. There is no known allergies, however patient claims that he hasn't been taking his medication regularly and the method of usage of the inhaler was incorrect.

Patients denies smoking for the past 1 year, and denies working in a polluted environment. There is no history of siblings having similar type of disease.

On examination, patient is breathless, despite of receiving oxygen 3l/min. There is tachycardia,he is hypertensive and afebrile, no cyanosis or pedal oedema. There is fine tremors in his hands but no flappng tremors.
On RS examination, barrel shaped chest, trachea is central, reduced chest expansion bilaterally, hyperresonant on percussion, cardiac dullness is obliterated, and liver dullness is present at the 7th intercostal space. On auscultation there is vesicular breath sounds with decreased intensity, prolonged expiration and rhonchi being present at all areas.


Diagnosis: acute exacerbation of copd

Discussion.

There are various predisposing factor for a patient to develop an acute exacerbation of copd, common factors are respiratory infection such as pneumonia, smoking and also polluted environment. However in this case is most likely due to default in medical therapy given to patient since the 1st episode of acute exacerbation.