History of Present Illness Occasional exertional dyspnea (SOB on walking 5 blocks Cough productive of whitish sputum (1 teaspoon full) (-) orthopnea, PND, chest pain, fever, weight loss Spontaneously resolve but would recur No consult Occasional exertional dyspnea (SOB on walking 5 blocks Cough productive of whitish sputum (1 teaspoon full) (-) orthopnea, PND, chest pain, fever, weight loss Spontaneously resolve but would recur No consult 15 years PTA 11 years PTA 8 years PTA Progression of dyspnea (3 blocks) (-) other associated symptoms Consulted: Chest x-ray done (unrecalled result); Unrecalled diagnosis; unrecalled medications during symptoms relief No follow up done Progression of dyspnea (3 blocks) (-) other associated symptoms Consulted: Chest x-ray done (unrecalled result); Unrecalled diagnosis; unrecalled medications during symptoms relief No follow up done Cough, blood streaked sputum, undocumented fever Dyspnea at rest Consulted: CXR (unrecalled result); unrecalled antibiotics & other meds for 7 days Relief of blood streaked sputum, fever, dyspnea at rest Cough, blood streaked sputum, undocumented fever Dyspnea at rest Consulted: CXR (unrecalled result); unrecalled antibiotics & other meds for 7 days Relief of blood streaked sputum, fever, dyspnea at rest Dyspnea, prod cough
History of Present Illness Persistence of symptoms Dyspnea at rest Persistence of symptoms Dyspnea at rest Persistence of symptoms Self medicated with Procaterol 25mcg/tab no relief Consulted at UST ERCD Persistence of symptoms Self medicated with Procaterol 25mcg/tab no relief Consulted at UST ERCD Cough with increased production of grayish sputum 2 pillow orthopnea (-) PND, chest pain, fever, weight loss, night sweats, malaise, anorexia No medications or consultations were done Cough with increased production of grayish sputum 2 pillow orthopnea (-) PND, chest pain, fever, weight loss, night sweats, malaise, anorexia No medications or consultations were done Persistence of exertional dyspnea (3 blocks), productive cough of whitish / greenish to grayish sputum & dyspnea at rest (3-5 times/year); Tx: Procaterol 25mcg/tab prn Interim 2 weeks PTA 1 day PTA Few hours PTA Dyspnea, prod cough
Past Medical History (+) Hypertension (2005) UBP 130/80, HBP 180/100 unrecalled drug, non-compliant (+) DM Type 2 (2007) unrecalled drug, non-compliant (-) PTB, (-) thyroid disease, (-) asthma, (-) cancer Medical none Surgical none Allergies, Blood transfusion
Family History (+) HPN-father, mother (+) DM- father (+) Heart disease- mother (+) PTB-sister (-) asthma, thyroid disease, cancer
Personal and Social History Smoker-168 pack years; (stopped April, 2009) Alcoholic drinker (1 bottle of gin/day since 16 years old) Denies illicit drug use Mixed diet more of meat and fish No tattoo
Physical Examination Conscious, coherent, wheelchair borne, purse-lip breathing, speaks in phrases BP 130/80mmHg (sitting) 120/80mmHg (lying), PR 82, regular, RR 26 regular, cpm, T 37.3°C Warm moist skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclera, no ptosis, isocoric at 2-3mm ERTL, (+) ROR, distinct margins, no edema, 2:3 A:V ratio OU; (+) dot blot hemorrhage on OS
Physical Examination Nasal septum midline, turbinates not congested, no alar flaring; No tragal tenderness, no aural discharge, R and L tympanic membrane intact; (-) central cyanosis, moist buccal mucosa, non- hyperemic PPW, tonsils not enlarged; (+) tense sternocleidomastoid, trachea deviated to the left, supple neck, thyroid not enlarged, non- palpable cervical lymphadenopathies; (-) carotid bruit, neck veins not distended
Physical Examination Symmetrical chest expansion, (+) supraclavicular and intercostal retractions, (+) barrel chest, (+) I:E 1:4, (-) abdominal paradox, decreased tactile fremiti on the right (T8 down), dull on percussion on the right (T8 down), decreased vocal fremiti and breath sounds on the right (T8 down), (+) egophony at the right (T8 down); (+) rales on right lower lung field (+) wheezes on all lung fields
Physical Examination Adynamic precordium, JVP 3 cm at 30 o, AB 6 th LICS AAL, not diffused or sustained, (-) heaves, lifts, thrills, S1 > S2 at the apex, S2 > S1 at the base, (-) S3, murmurs Flat abdomen, normoactive bowel sounds, soft, (-) tenderness, (-) masses, tympanitic in all quadrants, Liver span 8cm MCL, liver and spleen not palpable, traube’s space not obliterated, (-) CVA tenderness, (-) hepatojugular reflux Pulses full and equal, ABI 1, (-) cyanosis (-) edema (-) clubbing
Physical Examination Conscious, coherent, oriented to 3 spheres ; GCS 15 EOMs full and equal, V1V2V3 intact; can frown, can raise eyebrows, can smile; gross hearing intact, uvula midline, can shrug shoulders against resistance, can turn head against resistance, tongue midline on protrusion No muscle atrophy/hypertrophy, no fasciculation, MMT 5/5 all extremities Can do APST and FTNT with ease DTRs +2 on all extremities No Sensory deficits No babinski, no signs of meningeal irritation
Salient Features 69 y/o, M Chronic cough with sputum Resolve but recur Dyspnea 2 pillow orthopnea Hypertensive (2005) uncontrolled Diabetic (2007) uncontrolled (+) FH for HPN, DM and PTB 168 pack years Alcoholic beverage drinker In respiratory distress Tracheal deviation to the Left Barrel chest Prolonged I:E ratio Decreased tactile fremiti, vocal fremiti, breath sounds and dullness on percussion on the Right, T8 down Rales on the RLL Wheezes on all lung fields Dot-blot hemorrhage OS SubjectiveObjective
Assessment Obstructive lung disease, probably Chronic Obstructive Pulmonary Disease (COPD), in acute exacerbation probably secondary to Community acquired pneumonia (CAP), in patient, non ICU setting t/c pleural effusion, right Systemic arterial Hypertension (SAH) stage 2 Diabetes Mellitus, Type 2 t/c Diabetic Retinopathy
Chronic Obstructive Pulmonary Disease a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema. the airflow obstruction is generally progressive.
Pathology of COPD CENTRAL airways: Enlarged mucus secreting glands and an increase in the number of goblet cells are associated with mucus hypersecretion. PERIPHERAL airways: chronic inflammation leads to repeated cycles of injury and repair of the airway wall structural remodeling of the airway wall, with increasing collagen content and scar tissue formation, that narrows the lumen and produces fixed airways obstruction.
Pathophysiology Pathological changes in the lungs lead to corresponding physiological changes characteristic of the disease, including: (in order over the course) mucus hypersecretion, ciliary dysfunction, airflow limitation, pulmonary hyperinflation, gas exchange abnormalities, pulmonary hypertension, and cor pulmonale. Mucus hypersecretion and ciliary dysfunction lead to chronic cough and sputum production. These symptoms can be present for many years before other symptoms or physiological abnormalities develop.
Physical Examination of COPD Early: slowed expiration and wheezing on forced expiration. Obstruction progresses: hyperinflation becomes evident, and the AP diameter of the chest increases. The diaphragm becomes limited in its motion. Breath sounds are decreased, expiration is prolonged, and heart sounds often become distant. Coarse crackles may be heard at the lung bases. Wheezes are frequently heard, especially on forced expiration. End-stage COPD: Tri-pod position, use of accessory respiratory muscles of the neck and shoulder girdle, expiration through pursed lips and paradoxical indrawing of the lower interspaces is often evident. Cyanosis may be present. An enlarged, tender liver indicates heart failure Neck vein distention, especially during expiration due to increased intrathoracic pressure. Asterixis may be seen with severe hypercapnia.
Community Acquired Pneumonia Acute infection of pulmonary parenchyma Symptoms of acute infection Respiratory or general Maybe less prominent in the elderly Acute infiltrates on CXR Clinical findings such as localized rales No hospitalization within previous 14 days Excludes residents in long term care facilities
Diabetic Retinopathy Affects the circulatory system of the retina. Earliest phase: non-proliferative / background diabetic retinopathy. arteries in the retina become weakened and leak, forming small, dot- like hemorrhages. These leaking vessels often lead to swelling or edema in the retina and decreased vision. Next stage: Proliferative diabetic retinopathy. circulation problems oxygen-deprivation or ischemic new, fragile, vessels develop as the circulatory system attempts to maintain adequate oxygen levels within the retina (neovascularization) hemorrhage leak into the retina and vitreous, causing spots or floaters, along with decreased vision. Later phases: continued abnormal vessel growth and scar tissue may cause serious problems such as retinal detachment and glaucoma
ABI index resting ankle-brachial index of less than 1 is abnormal. If the ABI is: Less than 0.95, significant narrowing of one or more blood vessels in the legs is indicated. Less than 0.8, pain in the foot, leg, or buttock may occur during exercise (intermittent claudication). Less than 0.4, symptoms may occur when at rest. 0.25 or below, severe limb-threatening PAD is probably present.