Transcript Subjective Objective

ER CONFERENCE
Cacnio * Calimlim * Castillo * Cauilan * Causapin * Chu, D
* Chu, H * Co, J * Co, V * Cosico * De Leon
General Data
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V.N.
69 y/o
Male
Catholic
Married
Tondo, Manila
Kagawad
Patient; 70%
Chief Complaint : Dyspnea
History of Present Illness
Occasional exertional dyspnea (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
11 years
PTA
8 years
PTA
Dyspnea, prod cough
15 years
PTA
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
History 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 prn
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
Few hours
PTA
Dyspnea, prod cough
Interim
Persistence of symptoms
Dyspnea at rest
Persistence of symptoms
Self medicated with Procaterol 25mcg/tab  no relief
Consulted at UST ERCD
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
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(+) HPN-father, mother
(+) DM- father
(+) Heart disease- mother
(+) PTB-sister
(-) asthma, thyroid disease, cancer
Personal and Social History
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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
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(-) 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
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(-) 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
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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
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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, nonhyperemic PPW, tonsils not enlarged;
(+) tense sternocleidomastoid, trachea deviated to
the left, supple neck, thyroid not enlarged, nonpalpable cervical lymphadenopathies; (-) carotid
bruit, neck veins not distended
Physical Examination
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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
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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
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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
Subjective
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69 y/o, M
Chronic cough with sputum
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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
Objective
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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
Assessment
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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
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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
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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
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Pathological changes in the lungs lead to corresponding
physiological changes characteristic of the disease, including: (in
order over the course)
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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
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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
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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
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Acute infection of pulmonary parenchyma
Symptoms of acute infection
 Respiratory
or general
 Maybe less prominent in the elderly
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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
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RBS > 200 + symptoms of diabetes
FBS < 126
2 hr OGTT > 200
Diabetic Retinopathy
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Affects the circulatory system of the retina.
Earliest phase: non-proliferative / background diabetic retinopathy.
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Next stage: Proliferative diabetic retinopathy.
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arteries in the retina become weakened and leak, forming small, dotlike hemorrhages.
These leaking vessels often lead to swelling or edema in the retina and
decreased vision.
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
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resting ankle-brachial index of less than 1 is
abnormal. If the ABI is:
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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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