4History of Present Illness 15 yearsPTA11 years8 yearsOccasional exertional dyspnea (SOB on walking 5 blocksCough productive of whitish sputum (1 teaspoon full)(-) orthopnea, PND, chest pain, fever, weight lossSpontaneously resolve but would recurNo consultDyspnea, prod coughProgression of dyspnea (3 blocks)(-) other associated symptomsConsulted: Chest x-ray done (unrecalled result); Unrecalled diagnosis; unrecalled medications during symptoms reliefNo follow up done15 years- cough of <1 weejfrequencyCough, blood streaked sputum, undocumented feverDyspnea at restConsulted: CXR (unrecalled result); unrecalled antibiotics & other meds for 7 daysRelief of blood streaked sputum, fever, dyspnea at rest
5History of Present Illness 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 prnInterimDyspnea, prod cough2 weeksPTACough with increased production of grayish sputum2 pillow orthopnea(-) PND, chest pain, fever, weight loss, night sweats, malaise, anorexiaNo medications or consultations were done1 day PTAPersistence of symptomsDyspnea at restDyspnea while walking about 3 blocks away from home and climbing the stairs of 4-5 steps. This was accompanied by productive cough of grayish sputum amounting to 2 teaspoonfuls. Patient denied any presence of fever or vomiting. No consult was done or medications taken.dyspnea progressed now experienced even at rest. Still, no consult done or medications taken.Few hours PTA, there was recurrence of above symptom. Patient took Procaterol HCl (Meptin) 25 mcg/tab previously prescribed by a pulmonologist which he usually take as needed for difficulty of breathing. Patient denied any relief from the said medication. Persistence of the symptom prompted consult and subsequent admission.Few hoursPTAPersistence of symptomsSelf medicated with Procaterol 25mcg/tab no reliefConsulted at UST ERCDAdmission
6Past Medical History Medical (+) Hypertension (2005) UBP 130/80, HBP 180/100 unrecalled drug, non-compliant(+) DM Type 2 (2007) unrecalled drug, non-compliant(-) PTB, (-) thyroid disease, (-) asthma, (-) cancerSurgicalnoneAllergies, Blood transfusion
7Family History (+) HPN-father, mother (+) DM- father (+) Heart disease- mother(+) PTB-sister(-) asthma, thyroid disease, cancer
8Personal and Social History Smoker-168 pack years; (stopped April, 2009)Alcoholic drinker (1 bottle of gin/day since 16 years old)Denies illicit drug useMixed diet more of meat and fishNo tattooAlcohol content
11Physical ExaminationConscious, coherent, wheelchair borne, purse-lip breathing, speaks in phrasesBP 130/80mmHg (sitting) 120/80mmHg (lying), PR 82, regular, RR 26 regular, cpm, T 37.3°CWarm moist skin, no active dermatosesPink 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
12Physical ExaminationNasal 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
13Physical ExaminationSymmetrical 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
14Physical ExaminationAdynamic precordium, JVP 3 cm at 30o, AB 6th LICS AAL, not diffused or sustained, (-) heaves, lifts, thrills, S1 > S2 at the apex, S2 > S1 at the base, (-) S3, murmursFlat 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 refluxPulses full and equal, ABI 1, (-) cyanosis (-) edema (-) clubbing
15Physical ExaminationConscious, coherent, oriented to 3 spheres ; GCS 15EOMs 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 protrusionNo muscle atrophy/hypertrophy, no fasciculation, MMT 5/5 all extremitiesCan do APST and FTNT with easeDTRs +2 on all extremitiesNo Sensory deficitsNo babinski, no signs of meningeal irritation
16Salient Features 69 y/o, M Chronic cough with sputum Dyspnea SubjectiveObjective69 y/o, MChronic cough with sputumResolve but recurDyspnea2 pillow orthopneaHypertensive (2005) uncontrolledDiabetic (2007) uncontrolled(+) FH for HPN, DM and PTB168 pack yearsAlcoholic beverage drinkerIn respiratory distressTracheal deviation to the LeftBarrel chestProlonged I:E ratioDecreased tactile fremiti, vocal fremiti, breath sounds and dullness on percussion on the Right, T8 downRales on the RLLWheezes on all lung fieldsDot-blot hemorrhage OS
17AssessmentObstructive lung disease, probably Chronic Obstructive Pulmonary Disease (COPD), in acute exacerbation probably secondary to Community acquired pneumonia (CAP), in patient, non ICU settingt/c pleural effusion, rightSystemic arterial Hypertension (SAH) stage 2Diabetes Mellitus, Type 2t/c Diabetic Retinopathy
21Pathology of COPDCENTRAL 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.
22PathophysiologyPathological 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.
24Physical 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 failureNeck vein distention, especially during expiration due to increased intrathoracic pressure.Asterixis may be seen with severe hypercapnia.
31Community Acquired Pneumonia Acute infection of pulmonary parenchymaSymptoms of acute infectionRespiratory or generalMaybe less prominent in the elderlyAcute infiltrates on CXRClinical findings such as localized ralesNo hospitalization within previous 14 daysExcludes residents in long term care facilities
37Diabetic 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
39ABI indexresting 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.