성균관대학교 의과대학 손의영

Chief Complain 김O식, M/83 Dyspnea Onset : 2 weeks ago

Present Illness TB pleurisy 로 치료 받은 후에 간헐적으로 dyspnea 호소 Pneumonia w/ respiratory failure로 입원 후 치료받고 퇴원 2009.우울증 진단 후 1년간 medication 복용 Cough, dyspnea로 충주의료원 입원 치료 Maniac episode 보여 bipolar disorder 진단 이후 1년에 약 1차례 씩 감기로 인한 dyspnea로 입원 치료 함

Present Illness cough, yellowish sputum 증가 dyspnea aggravation  충주의료원 방문 Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원 Foley catheter insertion insomnia, hallucination 및 말이 많아지는 양상 보임 스스로 line remove 하려고 하며 irritability 발생 ABGA – 65.1 – 65.2 – 38.4 SpO2 91.7% CO2 retention aggravation 되어 보호자가 원하여 본원 내원

Other History PMHx. HTN/DM/Tb/hepatitis/Allergy ( + / + / - / - / - ) 약물력 Drugs for Depression (During 1 year) 수술력 없음 FHx. 특이사항 없음 SHx. Smoking: ex-smoker 30PA (30yr x 1 pack)

Review of system GW / EF ( + / + ) Weight change ( - ) Fever / chill ( - / - ) Headache / dizziness ( - / - ) Rhinorrhea / cough / sputum ( - / + / + ) : yellowish Dyspnea (+) : ATS grade III chest pain / palpitation ( - / - ) Anorexia / nausea / vomiting ( - / - / - ) abdominal pain / discomfort ( - / - ) Constipation / diarrhea ( - / - ) Hematemesis / melena / hematochezia ( - / - / - ) Urinary Sx ( - ) Arthralgia ( - ) Myalgia ( - )

Physical Exam V/S 140/83 mmHg ℃ G/AChronic ill-looking appearance MentalityAlert & well orientation HEENTnot anemic conjunctivae, anicteric sclerae Dehydrated tongue (-) PNS tenderness(-) PTH/PI (-/-) JVP (-) Neck VE (-) Cervical LNE (-/-) Thyroid enlagement (-) ChestSymmetric chest expansion Iregular heart beat w/o murmur Clean breathing sound w/o wheezing

Physical Exam Abdomen Soft & flat Bowel sound – normoactive No tenderness / rebound tenderness No shifting dullness Back No CVAT Extremities Skin rash(-)Clubbing (-) Joint ROM limitation (-) Joint swelling & stiffness (-) Joint deformity (-)

EKG

Imaging

Lab WBC ▲ x10³/μL Neut. ▲ 92.2% (seg.) Eo.0.1% RBC ▼ 3.80 x10³/μL Hb ▼ 11.3 g/dL Hct ▼ 36.1% PLT262,000/μL Protein ▼ 4.2 g/㎗ Albumin ▼ 2.7 g/㎗ Globulin ▼ 1.5 g/㎗ AST35 U/l ALT37 U/l ALP 77 U/l BUN21 mg/dL Cr 0.92 mg/dL BUN/Cr23.0 CRP ▲ 4.06 mg/dL Na140 mmol/ℓ K ▼ 3.4 mmol/ℓ Cl ▼ 96 mmol/ℓ

Problem List / Assessment Problem List #1. Dyspnea #2. Depression #3. Mania #4. Aggravation of Cough and Sputum #5. CO 2 retention #6. Leukocytosis #7. increased CRP Assessment #1, 4, 5, 6, 7 : R/O Acute Exacerbation of COPD #2, 3 : Bipolar disorder

AE of COPD Lung function test PEF < 100 L/min or PEV1 < 1.00 L ABGA Respiratory failure : PaO 2 50 mmHg in room air Life threatening condition :PaO 2 70 mmHg and pH < 7.30

AE of COPD – Etiology Primary Tracheobronchial infection Air pollution Secondary Pneumoniayellowish sputum, CT GGO, Pulmonary embolism but CT 특이소견 X Pneumothorax but CXR 특이소견 X Rib fracture / Chest trauma but Hx X Inappropriate use of sedatives, narcotics, β-blocking agents Right and/or Left heart failure or arrhythmias

AE of COPD – Treatment Controlled oxygen therapy 목표치 : PaO 2 > 60mmHg, SaO 2 > 90% 30분 후에 ABGA로 CO2 retention, acidosis 여부 파악 Bronchodilator therapy Short acting β2-agonist Glucocorticoids Antibiotics Ventilatory support