성균관대학교 의과대학 2007313075 손의영. Chief Complain 김O식, M/83 Dyspnea Onset : 2 weeks ago.

Case Presentation 성균관대학교 의과대학2007313075 손의영

Chief Complain

김 O 식 , M/83

DyspneaOnset : 2 weeks ago

Present Illness2011.02 TB pleurisy 로 치료 받은 후에

간헐적으로 dyspnea 호소

2000.03.09 Pneumonia w/ respiratory failure 로 입원 후 치료받고 퇴원

2009. 우울증 진단 후 1 년간 medication 복용

2009.12. Cough, dyspnea 로 충주의료원 입원 치료Maniac episode 보여 bipolar disorder 진단

이후 1 년에 약 1 차례 씩 감기로 인한 dyspnea 로 입원 치료 함

Present Illness2011.04.05 cough, yellowish sputum 증가

dyspnea aggravation 충주의료원 방문Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원

2011.04.06 Foley catheter insertion

2011.04.07 insomnia, hallucination 및 말이 많아지는 양상 보임

2011.04.09 스스로 line remove 하려고 하며 irritability 발생

ABGA 7.388 – 65.1 – 65.2 – 38.4 SpO2 91.7%CO2 retention aggravation 되어 보호자가 원하여 본원 내원

Other HistoryPMHx.

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 systemGW / EF ( + / + )Weight change ( - )Fever / chill ( - / - )Headache / dizziness ( - / - )Rhinorrhea / cough / sputum ( - / + / + ) : yellowishDyspnea (+) : ATS grade IIIchest pain / palpitation ( - / - )Anorexia / nausea / vomiting ( - / - / - )abdominal pain / discomfort ( - / - )Constipation / diarrhea ( - / - )Hematemesis / melena / hematochezia ( - / - / - )Urinary Sx ( - )Arthralgia ( - )Myalgia ( - )

Physical Exam V/S 140/83 mmHg - 108 - 24 - 36℃ G/A Chronic ill-looking appearance Mentality Alert & well orientation HEENTnot anemic conjunctivae, anicteric sclerae

Dehydrated tongue (-) PNS tenderness(-) PTH/PI (-/-) JVP (-) Neck VE (-)Cervical LNE (-/-) Thyroid enlagement (-)

Chest Symmetric chest expansionIregular heart beat w/o murmur Clean breathing sound w/o wheezing

Physical Exam Abdomen Soft & flat

Bowel sound – normoactive

No tenderness/rebound tender-ness

No shifting dullness Back No CVAT Extremities Skin rash(-) Clubbing (-)

Joint ROM limitation (-) Joint swelling & stiffness (-)

Joint deformity (-)

EKG

Imaging

LabWBC▲ 11.25 x10³/μL

Neut.▲ 92.2% (seg.)Eo. 0.1%

RBC▼ 3.80 x10³/μLHb▼ 11.3 g/dL

Hct▼ 36.1%PLT 262,000/μLProtein▼ 4.2 g/ ㎗Albumin▼ 2.7 g/ ㎗Globulin▼ 1.5 g/ ㎗

AST 35 U/lALT 37 U/lALP 77 U/lBUN 21 mg/dLCr 0.92 mg/dLBUN/Cr 23.0CRP▲ 4.06 mg/dLNa 140 mmol/ℓK▼ 3.4 mmol/ℓCl▼ 96 mmol/ℓ

Problem List / AssessmentProblem List

#1. Dyspnea#2. Depression#3. Mania#4. Aggravation of Cough and Sputum#5. CO2 retention#6. Leukocytosis#7. increased CRP

Assessment#1, 4, 5, 6, 7 : R/O Acute Exacerbation of COPD#2, 3 : Bipolar disorder

AE of COPDLung function test

PEF < 100 L/min or PEV1 < 1.00 L

ABGARespiratory failure : PaO2 < 60mmHg and/or

SaO2 < 90% w/ or w/o PaCO2 > 50 mmHg in room air

Life threatening condition : PaO2 < 60 mmHg andPaCO2 > 70 mmHg andpH < 7.30

AE of COPD – Etiology Primary

Tracheobronchial infectionAir pollution

SecondaryPneumonia yellowish 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 – TreatmentControlled oxygen therapy

목표치 : PaO2 > 60mmHg, SaO2 > 90%30 분 후에 ABGA 로 CO2 retention, acidosis 여부 파악

Bronchodilator therapyShort acting β2-agonist

GlucocorticoidsAntibioticsVentilatory support