Number 44 Male seventy four years

Chief complaint: repeated cough, dyspnea for three years, recrudescence for two
months and exacerbation two days ago.
Present illness: Three years ago the patient began to dyspnea, cough with a few white
mucous sputum, without fever and chest pain after catching a cold. The symptoms
were obvious, repeated in spring and winter, and more and more serious in the next
years. Above symptoms were repeated after catching a cold again two months ago. So
the patient saw a doctor, and took some herbs for therapy in the Yichang hospital of
T.C.M.. His symptoms were alleviated. Two days ago, his cough and dyspnea were
aggravated. He felt breathless even at rest, without fever and chest pain. In order to
treatment, He went to our hospital, and was received to respiratory department.
His spirit, sleep, appetite were normal, stool and urine were normal, too, physical
strength was descending. His weight was lost for 3 kilograms.
Past history
General health status: normal.
Operation history: No history of surgery
Infection history: No history of tuberculosis or hepatitis.
Allergic history: no allergic drugs.
Traumatic history: No traumatic history
Systemic review
Respiratory system: emphysema in 2002
Circulation system: hypertension for ten years, BP was 160/90 mmHg without drugs.
Personal history
He was born in Yichang city, Hubei Province. He smoked for 45 years with 20
cigarettes a day, and gave up smoking in 1993. He drank alcohol for 45 years with
125 grams a day, and gave up drinking in 2003.
Physical examination
Vital signs: Temperature 36.4℃, Pulse 72bpm, RR 24bpm, BP 130/70mmHg
Chest and lung:Inspection/ Palpation/ Percussion/Auscultation:
Assistant examination
Lung function(spirometry ) FEV1=40.7%predicted, FEV1/FVC=43.70%predicted
Chest X ray plate: chronic bronchitis and emphysema, left lung infection
Chest CT: chronic bronchitis, left upper pathologic changes (TB, carcinoma, etc)
Lab. Exam:
Blood routine test: WBC 8.47×109/L, N 80.8%, L 10.6%
Sputum culture: normal bacteria in mouth and throat
Arterial gas analysis: Sep 1st, 2006. Pco2 32.2mmHg, Po2 57.6mmHg
Sep 4th, 2006. Pco2 32.2mmHg, Po2 57.6mmHg
Diagnosis
Acute exacerbation of COPD
Left lung infection
Therapy
1 antibiotics; 2 expectorant(gelomyrtol); 3 bronchodilators (Long-acting β2-agonist,
Aminophlline); 4 controlled oxygen; 5 corticosteroid; 6 mechanical ventilation;