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ER Conference

ER Conference. Cacnio * Calimlim * Castillo * Cauilan * Causapin * Chu, D * Chu, H * Co, J * Co, V * Cosico * De Leon. General Data. V.N. 69 y/o Male Catholic Married Tondo , Manila Kagawad Patient; 70%. Chief Complaint : Dyspnea. History of Present Illness. 15 years PTA

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ER Conference

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  1. ER Conference Cacnio * Calimlim * Castillo * Cauilan * Causapin * Chu, D * Chu, H * Co, J * Co, V * Cosico * De Leon

  2. General Data • V.N. • 69 y/o • Male • Catholic • Married • Tondo, Manila • Kagawad • Patient; 70%

  3. Chief Complaint : Dyspnea

  4. History of Present Illness 15 years PTA 11 years PTA 8 years PTA Occasional exertionaldyspnea (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 Dyspnea, prod cough 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

  5. History of Present Illness Persistence of exertionaldyspnea (3 blocks), productive cough of whitish / greenish to grayish sputum & dyspnea at rest (3-5 times/year); Tx: Procaterol 25mcg/tab prn Interim Dyspnea, prod cough 2 weeks PTA 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 1 day PTA Persistence of symptoms Dyspnea at rest Few hours PTA Persistence of symptoms Self medicated with Procaterol 25mcg/tab  no relief Consulted at UST ERCD Admission

  6. Past Medical History

  7. Family History • (+) HPN-father, mother • (+) DM- father • (+) Heart disease- mother • (+) PTB-sister • (-) asthma, thyroid disease, cancer

  8. 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

  9. Review of System • (-) pallor, (-) fatigue • (-) jaundice, (-) hypo/hyperpigmentation • (+) blurring of vision, (-) lacrimation, (-) eye pain, redness, (-) itchiness • (-) deafness, discharge, tenderness • (-) colds, (-) discharge (-) epistaxis • (-) sore throat (-) sores, fissures, bleeding gums • (-) neck stiffness, limitation of movement, masses • (-) constipation, (-) abdominal pain, (-) diarrhea, (-) hematochezia, (-) melena, (-) nausea, (-) vomiting

  10. Review of System • (-) oliguria, (-) hematuria, (-) dysuria (-) urgency (-) frequency (-) discharge • (-) muscle pain • (-) palpitation, (-) polydipsia, (-) polyuria, (-) polyphagia, (-) heat-cold intolerance • (-) Poor wound healing, (-) easy bruisability • (-) Sensory deficit, (-) seizures • (-) depression, (-) hallucinations

  11. 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

  12. 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

  13. 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

  14. Physical Examination • Adynamicprecordium, 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, 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

  15. 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

  16. Salient Features Subjective Objective • 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

  17. 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

  18. DISCUSSION

  19. 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.

  20. Differential Diagnosis of COPD

  21. 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.

  22. Pathophysiology • Pathological changes in the lungs lead to corresponding physiological changes characteristic of the disease, including: (in order over the course) • mucus hypersecretion, • ciliarydysfunction, • airflow limitation, • pulmonary hyperinflation, • gas exchange abnormalities, • pulmonary hypertension, • and corpulmonale. • 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.

  23. Clinical Features of COPD

  24. 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 indrawingof the lower interspaces is often evident. Cyanosis may be present. • An enlarged, tender liver indicates heart failure • Neckvein distention, especially during expiration due to increased intrathoracicpressure. • Asterixismay be seen with severe hypercapnia.

  25. GOLD Classification of Stable COPD

  26. GOLD Classification of Stable COPD Patient usually not aware of abnormal lung function

  27. GOLD Classification of Stable COPD Worsening of airflow limitation, progression of symptoms w/ SOB typically on exertion

  28. GOLD Classification of Stable COPD Further worsening of airflow limitation, increased SOB and frequent exacerbations that impact the QOL of the patient

  29. Acute Exacerbation of COPD • Sustained worsening of the patient’s symptoms from the usual stable state that is beyond normal day to day variation • Onset usually acute (1-3 days)

  30. Symptoms of COPD Exacerbation

  31. 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

  32. Etiologies of CAP

  33. Typical vs Atypical Pneumonia

  34. CURB 65

  35. JNC 7

  36. Diabetes Mellitus • RBS > 200 + symptoms of diabetes • FBS < 126 • 2 hr OGTT > 200

  37. 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

  38. Diabetic Retinopathy

  39. 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.

  40. Thank you for listening 

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