Case Study: COPD and Comorbidities in a 66-Year-Old Female

Audrey Thomas, a 66-year-old female with COPD, is suffering from acute severe asthmatic attack, hypertension, obesity, osteoporosis, chronic kidney disease, and type 2 diabetes mellitus. This case study discusses the symptoms, risk factors, and management of these comorbidities.

PATIENT SUMMARY
Audrey Thomas a female, aged 66 years, who lived alone was suffering from COPD based both
laboratory diagnosis and the clinical manifestations such as difficulty in breathing, severe
dyspnoea, high respiratory rates, raised heart beat rates, hypersecretion of mucus. Moreover, the
patient suffered a myriad of conditions that could be attributed to her lifestyle or as result of
Primary conditions such include hypertension, obesity, osteoporosis, and chronic kidney disease
among others.
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a group of lung diseases that cause
inflammation leading to bronchoconstriction and airway resulting to difficulty in breathing
(Nagaratnam et al., 2018). Some of the main diseases that constitute the COPD include,
emphysema, acute severe asthmatic, and chronic bronchitis. According to Vogelmeier et al.
(2017), damage to the airways inhibits the gaseous exchange in the lungs. Smoking, infection
caused by virus and bacteria, and air pollution results to exacerbations of COPD indicative of
worsening of the underlying chronic inflammation of the airways, and the frequency of the
exacerbations is one of the important determinants of health-related quality of life a person (Divo
et al., 2015).
Case of Audrey Thomas: Day 1
Q1.
Audrey is suffering from acute severe asthmatic attack based on clinical manifestations exhibited
such as severe dyspnoea, high respiratory rate at 32 breaths/ minutes, her heart rate is 120 beats
per minute, coughs, and hypersecretion of mucus. According to Hazeldine (2013), symptoms of
acute severe asthma include Dyspnoea, Cough, respiratory rate ≥25 breaths/minute, Heart rate ≥
110 beats/minute. The acute asthmatic attack happens when person is exposed to an allergen
provoking an immune reactions leading to production of inflammatory mediators such as IgE
and mast cells among others. Immunological response results to bronchoconstriction,
bronchospasm, and hypersecretion of mucus (Whitsett and Alenghat (2015). Acute severe
asthmatic attack not only affect normal functioning of the lower respiratory tract such as trachea,
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bronchi, and the bronchioles but also the general pulmonary function is affected leading to
adverse symptoms experienced by the asthmatic patient (Hamid, Mahboub, & Ramakrishnan,
2018).
Q2.
During acute severe asthmatic attack there is reduced maximum expiratory volume per second,
reduced respiratory rates, therefore, the body compensate for this physiological changes by
cardiovascular system increasing the heart rate beat/minute to ensure availability of oxygen in
vital organs (Brinkman, & Sharma, 2018). Audrey experienced increased respiratory rate of up to
32 breaths per minutes and high heart rate ≥ 110 beats/minute. According to Kaufman (2012), in
acute severe asthma the patient’s respiratory rate of is increased to ≥25 breaths/minute and high
heart rate of ≥ 110 beats/minute to compensate for adverse clinical symptoms.
Q3
The Audrey is more likely to suffering from respiratory infections resulting to COPD. Some of
the risk factors that faced by Audrey are causal factors including smoking. According to
Kaufman (2012), environmental allergens such as cigarette smoking greatly influences
susceptibility to the development of acute severe asthmatic attack among the predisposed
persons. The long use of corticosteroid drugs by Audrey in the management of acute asthma
attack and her advanced age exposes her to more secondary infections caused by viral or
bacterial. For example, a study in China by Zhang et al. (2015), revealed that persons aged 40
years and above are 8.2 times prone to bacterial chronic bronchitis compared to the general
population. According to Hewitt et al. (2016), exacerbations of COPD can be caused by upper
respiratory viral infections such as Influenza A virus and Streptococcal pneumonia.
Q4.
Audrey is obese hence limiting his mobility, she spends most of the time sited in lounge room,
she has increased systemic inflammations, and she has been smoking for a long period.
Therefore, she has high risk of developing pulmonary embolism based on her condition and life
style. According to Kim et al. (2014), COPD patient with history of smoking, immobile, and
having systemic inflammation are at a high risk of developing pulmonary embolism. To prevent
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the development of pulmonary Audrey should be involved in physical activities and she should
be adviced to quit smoking.
Case of Audrey Thomas: Day 2
Q5.
Audrey may have developed muscle atrophy due to her sedentary life style which makes her
physically inactive and her advanced age is a risk factor leading to her falling and fracture.
Audrey would be suffering from osteoporosis which is low bone density and is common among
post-menopausal other risk factors include smoking, long term use of corticosteroids. Moreover,
bone resorption increases with menopause which is a risk factor for development of bone disease
(Sheu & Center, 2017). Audrey could later suffer chronic lower back pain and Osteoarthritis
attributed to her advance age and lack of physical activity.
Q6.
Audrey’s advanced age, gender, lifestyle, and being obese could have greatly contributed to the
fracture. These factors make person prone to osteoporosis and osteoarthritis caused by oxidative
damage, cartilage thinning, and bone resorption (Basedow et al., 2015). Moreover, studies have
established that women are at high risk of having bone fractures as compared to their male
counterparts this has been attributed to menopause where women experiences reduces oestrogen
levels (Australian Institute of Health and Welfare [AIHW], 2018 ). For example, in Australia
osteoarthritis has been cited as highly disabling and the high prevalence has been attributed to
ageing and increasing obesity of the population (Basedow et al., 2015).
Q7.
Jeon et al. (2014), established that there was a correlation between loss of bone mineral density
and the respiratory disease including bronchial asthma. Audrey condition of COPD has effect on
the normal lung function. Reduced lung function caused by airway inflammation and obstruction
increases the chances of bone disease and smoking has been cited as plausible explanation for
the occurrence of both respiratory disease and bone disease (Jeon et al., 2014).
Case of Audrey Thomas: Day 3
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Q8.
Audrey experience polyuria, this is due to the fact that when glucose is passed out in urine water
it creates osmotic pressure, and hence, more water will follow and passed out in urine increasing
the urine volume. The management of hyperglycemia involves fluid replacement, insulin
replacement, and electrolyte replacement.
Q9.
Audrey has high blood sugar of 13.5 mmol/l, whereas the blood sugar of ≥ 11.1 mmol/l indicates
type 2 diabetic mellitus (WHO, 2016). Therefore, she is suffering from type 2 diabetic mellitus.
Furthermore, Oral glucose tolerance test (OGTT) can also be conducted to establish her rate of
glucose utilization after 2 hours. World Health Organization experts on diabetic have
recommended diabetic patient to have Glycated haemoglobin with (HbA1c) of ≥6.5%, while
those at high risk of progression to diabetic to have values between 6.0-6.4% (WHO, 2016).
Therefore, Audrey recorded HbA1c of 12% which qualifies her for being diabetic.
Q10.
Audrey is more likely to suffer myocardial ischaemia based on her increased demand for oxygen
with increased heart rate as presented. Moreover, Audrey has a lifestyle and conditions puts her
at risk of developing myocardial ischaemia including smoking, obesity, sedentary life,
inflammation. Myocardial ischaemia can be prevented by patient avoiding smoking, engaging in
more physical activities (Li et al., 2015). If Audrey develops myocardial ischaemia and it’s not
managed well this can results to acute myocardial infarction (MI). MI can be prevented by
control the occurrence of myocardial ischaemia (Craft et al., 2015).
Audrey is at a high risk of developing hypertension. The risk factors associated with Audrey
include smoking, obesity, hyperglycemia, and having reached menopausal age. Audrey can
prevent the developing of hypertension by regularly involving in physical activity, avoiding high
sodium intake, and cessation of smoking. Due to the fact that Audrey is also suffering from
diabetes mellitus she is at a high risk of developing chronic kidney disease.
Case of Audrey Thomas: Day 4
Q1.
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Audrey is suffering from Gastroesophageal Reflux Disease (GERD). According to Katz, Gerson,
and Vela (2013), GERD occurs when acidic stomach juices, reflux to esophagus and respiratory
diseases such as asthma are a risk factor. Episodes of asthmatic attack results to relaxation of
lower esophageal sphincter enabling the stomach content to flow back into the esophagus area.
At the same time, Audrey has a high BMI of 40 which makes obese, this puts him at high risk of
developing GERD.
Q2.
Several episodes of acidic content of the stomach causes the breakdown of protective mucosal
lining leading to ulceration of underlying stomach tissue layers causing bleeding. At the same
time, hypersecretion of HCL, pepsin, lack of bicarbonate worsens the situation causing peptic
ulcers. According to Craft et al. (2015), more stomach epithelium damage leads to more
secretion of histamine resulting to more hydrochloric acid release in the stomach causing more
bleeding in the stomach. Whenever there is a lot of bleeding in the stomach this can result to
hematemesis which is vomiting of redly blood, more stomach hemorrhage results to
hematochezia, and more haemolyses takes place in the liver the broken down blood forms heam
that is passed into stool in different forms including Melena or occult. According to McPherson
and Pincus (2017), acute gastrointestinal bleeding have clinical manifestation including
Hematemesis, melena, and hematochezia.
Case of Audrey Thomas: Day 5
Q1.
Audrey has BMI of 40.4 and waist circumference value of 125 cm which is which makes her
severe obese, this is due to the fact that BMI of > 30, and WC ≥ 88 is indicator of severe obesity
as suggested by (Craft & Gordon, 2015). Audrey need to engage in more physical activity.
Q2.
LDL is bad cholesterol hence, raised value as in the case of Audrey is suggestive of
hypertension. According to Yuan, Naito, & Nakajima (2018), the raised level of LDL is
suggestive of hypertension. Whereas, HDL is an indicator of good health, hence low value as
seen in this case is not good it’s suggestive of risk of hypertension. Albumin is transport protein
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synthesized in the liver, lower value of albumin as seen in this case is indicative of
malfunctioning liver. The high level of ammonia indicates high protein catabolism. Whereas,
high levels of bilirubin indicates hemolysis. According to Yuan et al. (2018), steatosis is a major
cause of hepatomegaly in patients with diabetes caused by insulin resistance rather than glycemic
control. Audrey is also suffering from obesity due to the fact that she has a BMI of 40. Having
waist circumference of 125 cm indicates that Audrey suffer from Non-alcoholic fatty liver
disease (NAFLD.
Q3.
Audrey having registered weight circumference of 125 cm indicated she might be suffering from
Non-alcoholic fatty liver disease (NAFLD). NAFLD results to wide range of conditions from
steatosis to liver cirrhosis. The diagnostic parameters of NAFLD include high BMI, and high
waist circumference as indicated in the case of Audrey.
Q4.
Audrey legs will develop swelling (oedema) caused by effects on the oncotic pressure, this is due
to fact that more albumin is lost in the urine (macroalbuminuria). Audrey might develop diabetic
foot and her fractured hips may not heal quite well.
Case of Audrey Thomas: Day 6 (final day for Assessment part B)
Q1.
Audrey legs will develop swelling (oedema), this is due to fact that more albumin is lost in urine
(macroalbuminuria), this condition affects the oncotic pressure.
Q2.
Angiotensin Converting Enzyme (ACE) drugs such as Enalapril are quite important in
management of both hypertension and chronic kidney disease. In the case of Audrey the ACE
drugs benefits include reduced blood pressure and proteinuria which helps in reduction of kidney
damage (Webster et al., 2017). At the same time, lipid lowering drugs such Atorvastatin helps in
reducing the level of bad plasma lipid such as low density lipoproteins (LDL) which cause
narrowing of blood vessels leading to hypertension. According to Miller (2016), in treatment and
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management of chronic kidney patient the blood pressure should be maintained at less than
130/80mmHg.
Q3.
Audrey will be experiencing polyuria caused by macroalbuminuria, in situations where a
patient’s passes protein in urine such as albumin there is polyuria. Albumin cases oncogenic
pressure that will allow more water to flow back into the kidney tubules from the surrounding
cells, hence, large volume of urine being passed out eventually. The urine will have turbid and
cloudy appearance due to the large amount of albumin being passed out in the urine.
Q4.
Audrey is likely to suffer from some of the neurological complication including cerebral oedema
which will be caused by high arterial pressure and hypoalobuminaemia. When there is no proper
management of cerebral oedema it results to cranial pressures (Craft and Gordon, 2015). At the
same time, Audrey is at high risk of developing stroke due to uncontrolled hypertension, obese,
diabetes mellitus, she is regular smoker, and she has advanced age which is within menopause
state. According to Craft and Gordon (2015), the risk factors for developing stroke include
smoking, hypertension, advanced age, and obesity.
CONCLUSION
In the industrialised countries, COPD is a major cause of morbidity and mortality. Therefore, a
good management of COPD include both Pharmacological therapy and nursing management
strategies. Some of the risk factors for COPD include gender, age, lifestyle such as smoking, and
obesity. Moreover, primary and correct diagnosis of COPD and the patient’s behavioural change
is essential in management and treatment of COPD.
References
Australian Institute of Health and Welfare. (2018). Retrieved from
https://www.aihw.gov.au/reports/older-people/older-australia
glance/contents/demographics-of-older-australians.
Basedow, M., Williams, H., Shanahan, E. M., Runciman, W. B., & Esterman, A. (2015).
Australian GP management of osteoarthritis following the release of the RACGP
7

guideline for the non-surgical management of hip and knee osteoarthritis. BMC research
notes, 8(1), 536.
Brinkman, J. E., & Sharma, S. (2018). Physiology, Alkalosis, Respiratory.
Chronic musculoskeletal conditions Overview. (2018, July 24). Retrieved October 10, 2018,
from https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/
chronic-musculoskeletal-conditions/overview.
Craft, J., Gordon, C., Huether, S. E., McCance, K. L., & Brashers, V. L. (2015). Understanding
pathophysiology-ANZ adaptation. Elsevier Health Sciences.
Divo, M. J., Casanova, C., Marin, J. M., Pinto-Plata, V. M., de-Torres, J. P., Zulueta, J. J., ... &
Davila, R. B. (2015). Chronic obstructive pulmonary disease comorbidities network.
European Respiratory Journal, ERJ-01716.
Hamid, Q., Mahboub, B., & Ramakrishnan, R. K. (2018). Asthma-chronic obstructive
pulmonary disease overlap: A distinct pathophysiological and clinical entity. In Asthma,
COPD, and Overlap (pp. 55-66). CRC Press.
Hazeldine, V. (2013). Pharmacological management of acute asthma exacerbations in adults.
Nursing Standard (through 2013), 27(33), 43.
Hewitt, R., Farne, H., Ritchie, A., Luke, E., Johnston, S. L., & Mallia, P. (2016). The role of
viral infections in exacerbations of chronic obstructive pulmonary disease and asthma.
Therapeutic advances in respiratory disease, 10(2), 158-174.
Jeon, Y. K., Shin, M. J., Kim, W. J., Kim, S. S., Kim, B. H., Kim, S. J., ... & Kim, I. J. (2014).
The relationship between pulmonary function and bone mineral density in healthy
nonsmoking women: the Korean National Health and Nutrition Examination Survey
(KNHANES) 2010. Osteoporosis International, 25(5), 1571-1576.
Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management
of gastroesophageal reflux disease. The American journal of gastroenterology, 108(3),
308.
8

Kaufman, G. (2012). Asthma: assessment, diagnosis, and treatment adherence. Nurse
Prescribing, 10(7), 331-338.
Kim, V., Goel, N., Gangar, J., Zhao, H., Ciccolella, D. E., Silverman, E. K., ... & High-Risk-
COPD Screening Study Group. (2014). Risk factors for venous thromboembolism in
chronic obstructive pulmonary disease. Chronic Obstructive Pulmonary Diseases: Journal
of the COPD Foundation, 1(2), 239.
Li, L., Yiin, G. S., Geraghty, O. C., Schulz, U. G., Kuker, W., Mehta, Z., ... & Study, O. V.
(2015). Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient
ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology,
14(9), 903-913.
McPherson, R. A., & Pincus, M. R. (2017). Henry's Clinical Diagnosis and Management by
Laboratory Methods E-Book. Elsevier Health Sciences.
Miller, B. (2016). 7 Keys to Normalise Your Cholesterol Level: The higher your cholesterol
level the more rapidly plaque develops & clogs your arteries. Oak Publication Sdn Bhd.
Nagaratnam, N., Nagaratnam, K., Cheuk, G., Nagaratnam, N., Nagaratnam, K., & Cheuk, G.
(2018). Chronic Obstructive Pulmonary Disease (COPD). Geriatric Diseases: Evaluation
and Management, 89-98.
Ni, O. M., Crowson, C. S., Gabriel, S. E., Roger, V. L., & Amin, S. (2017). Fragility Fractures
Are Associated with an Increased Risk for Cardiovascular Events in Women and Men
with Rheumatoid Arthritis: A Population-based Study. The Journal of rheumatology,
44(5), 558-564.
Sheu, A., & Center, J. (2017). Osteoporosis in postmenopausal women: key aspects of
prevention and treatment
Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., ... &
Frith, P. (2017). Global strategy for the diagnosis, management, and prevention of
chronic obstructive lung disease 2017 report. GOLD executive summary. American
journal of respiratory and critical care medicine, 195(5), 557-582
9

Webster, A. C., Nagler, E. V., Morton, R. L., & Masson, P. (2017). Chronic kidney disease. The
Lancet, 389(10075), 1238-1252.
Whitsett, J. A., & Alenghat, T. (2015). Respiratory epithelial cells orchestrate pulmonary innate
immunity. Nature immunology, 16(1), 27.
World Health Organization. (2016). Use of glycated haemoglobin (HbA1c) in the diagnosis of
diabetes mellitus: abbreviated report of a WHO Consultation. Geneva; 2011. There is no
corresponding record for this reference
Yuan, Y., Naito, H., & Nakajima, T. (2018). The Role of Cholesterol in the Pathogenesis of
Hypertension-Associated Nonalcoholic Steatohepatitis. In Cholesterol-Good, Bad and the
Heart. IntechOpen.
Zhang, T., Chen, P., Chen, C., Kuang, J., Wang, C., Yan, X., & Yang, X. (2015). Efficacy and
safety of moxifloxacin injection in treatment of acute exacerbation of chronic bronchitis.
Community Acquired Infection, 2(3), 93.
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