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

ER CONFERENCECacnio * 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 IllnessOccasional 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 consult

15 yearsPTA

11 years PTA

8 yearsPTA

Progression of dyspnea (3 blocks) (-) other associated symptomsConsulted: Chest x-ray done (unrecalled result); Unrecalled diagnosis; unrecalled medications during symptoms reliefNo follow up doneCough, 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

Dysp

nea,

pro

d c

ough

History of Present Illness

Persistence of symptomsDyspnea at rest

Persistence of symptoms Self medicated with Procaterol 25mcg/tab no relief Consulted at UST ERCD

Cough with increased production of grayish sputum2 pillow orthopnea(-) PND, chest pain, fever, weight loss, night sweats, malaise, anorexiaNo medications or consultations were done

ADMISSION

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 weeksPTA

1 day PTA

Few hoursPTA

Dysp

nea,

pro

d c

ough

Past 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, (-) cancer

Surgical

• none

Allergies, Blood transfusion

• none

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

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

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

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 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

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

Subjective Objective

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

DISCUSSION

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.

Differential Diagnosis of COPD

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.

Clinical Features of COPD

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.

GOLD Classification of Stable COPD

GOLD Classification of Stable COPD

Patient usually not aware of abnormal lung function

GOLD Classification of Stable COPD

Worsening of airflow limitation, progression of symptoms w/ SOB typically on exertion

GOLD Classification of Stable COPD

Further worsening of airflow limitation, increased SOB and frequent exacerbations that impact the QOL of the patient

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)

Symptoms of COPD Exacerbation

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

Etiologies of CAP

Typical vs Atypical Pneumonia

CURB 65

JNC 7

Diabetes Mellitus

RBS > 200 + symptoms of diabetes FBS < 126 2 hr OGTT > 200

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

Diabetic Retinopathy

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.

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