RTRMF College of Medicine

Group 3B: Parena, Plimaco-Garcia, Pumanes, Ramas

Preceptor: Dr. Pilipinas Jaya
CASE #2:

Date and Time of Interview: July 5, 2017 at 2PM

Source(s) of Information: Patient, daughter and daughter-in-law
Source(s) of Referral: None
Reliability: 90%

I. IDENTIFYING DATA:
E.N. is a 60 year old, female, who is separated and residing in Sta. Rita, Samar,
Filipino, Roman Catholic, was admitted for the first time last June 29, 2017 @ 11:00 a.m.

II. CHIEF COMPLAINT:

Difficulty of breathing

III. HISTORY OF PRESENT ILLNESS:

2 weeks PTA, patient had a sudden onset of productive cough to a whitish

sticky sputum amounting to 5 ml per cough this was accompanied by dyspnea with
exertion such as grass cutting and doing some of her household chores, easy fatiguability
and a low grade fever. No consult was done nor medications were taken. Patient just
stayed at home and rest. By night her fever subsided and did not recur. No chest pain, no
palpitations no edema, no hemoptysis, no urticaria, no colds, no chills.
8 days PTA patients cough still persisted now associated with a yellowish
sputum without fever and now associated with a tight global headache which was
aggravated whenever the patient was coughing. The patient also experienced a diffused
squeezing abdominal pain in all quadrants with a PRS of 6,. This prompted the patient to
take Rexidol forte 500mg once which provided relief from her headache but the diffuse
abdominal pain was still present but now lessened. Her abdominal pain only lasted for 2
days. No other medications were taken and still no consult was done. No chest pain, no
palpitations no edema, no hemoptysis, no urticaria, no sneezing.
4 days prior to admission patients cough still persisted associated with dyspnea
to moderate activities, shortness of breath and easy fatiguability this prompted the
patient to sought for consult a their nearby health center. She was given Salbutamol via a
nebulizer and was prescribed of Salbutamol in oral preparation and cotrimoxazole. The
patient was not able to take the antibiotic medication due to financial reasons.

1 day PTA patients cough worsened this was now associated with dyspnea with mild
activities and orthopnea which can only be relieved with the patent in orthopneic
position. This prompted the patient to seek consult hence her admission to this institution
IV. PAST MEDICAL HISTORY

Childhood Illnesses: the patient was not able to recall having any kind of childhood
illness
Allergies: Patient is allergic to egg and chicken.
Adult Illnesses:
Medical: No hypertension, no diabetes, No asthma
Patient claims to have a long standing cough due to her pi-
ang (fracture). She would only try to manage it by using herbal
medications and herbal liniments
Surgical: No previous surgical operation.
Obstetrical : Menarche at 14 years old with regular menses. Consumes 4
pads per menstruation of 4 days duration. G6P6, with first
pregnancy at 20 years old. No history of contraceptive use. All
of the 6 pregnancies were delivered at home via NSVD in which
her first 4 children were delivered by her own mother and the
other 2 by a kumadrona. Menopause was at 42 years old,
with no associated abnormal symptoms.
Psychiatric: No psychiatric record.

V. FAMILY HISTORY

The patients mother is already deceased, however patient was not able to
recall the age and cause of death. Her father is still alive and is apparently well.
She is the 2nd among 8 children, 3 of whom she lost contact with while the other 4
are alive with no known diseases. She has 4 children from her 1 st husband and 2
more from the 2nd husband. Her two daughters have history of pre-eclampsia while
other children are alive and apparently well. No other known familial diseases
such as DM, Cancer, Cardiovascular and Autoimmune diseases.

VI. PSYCHO-SOCIAL HISTORY

Patient was not able to finish primary education and worked as a farmer at an
early age. She started to smoke tobacco at 10 years old and used to have 5-6 sticks
daily or 12.5-15 pack years. She just stopped recently (June 2017) following
persistent productive coughing and difficulty of breathing have become apparent.
She used to drink tuba on occasions and can consume about 3-4 glasses per
session. She usually eats rice, fish and vegetables and does not drink as much
water. She lives with her family in a house made up of light materials and with
adequate ventilation. They use firewood for cooking. Their source of water used
 for drinking is from a faucet while for household purposes is from a nearby water
pump. They dispose their garbage in a compost pit at their backyard.
She usually awakens at 4 a.m and retires to bed at 8 p.m. She claims that
financial constraint is her primary source of stress.

VII. REVIEW OF SYSTEMS

General: Has easy fatigability and is ambulatory. No weight loss, no

weakness, no trouble sleeping
Skin: No lumps, sores, changes in color of skin. No change of color in
nails, hair and moles.
Head: No headache, dizziness and light headedness.
Eyes: No blurring of vision, redness, excessive tearing, spots, and
flashing lights.
Ears: Patient has good hearing. No tinnitus, vertigo, earaches, or
discharges.
Nose: No frequent episodes of colds, dryness, nasal stuffiness,
discharge, itching, nosebleeds, or inflamed sinus.
Mouth/throat: Has throat discomfort (itchiness). No dry mouth, hoarseness
of voice, bleeding of gums, sores.
Neck: No nuchal pain. No lumps, pain, and stiffness.
Breast: No lumps, no pain, no discomfort, nor nipple discharge.
Respiratory: Has a productive cough to a yellow sputum. No difficulty of
breathing, orthopnea, no pleurisy, no wheezing
Cardiovascular: No palpitations, orthopnea, dyspnea and edema.
Gastrointestinal: loss of appetite. No dysphagia, heartburn, nausea, with
normal bowel movements per 24hrs period. No pain during
defecation.
Urinary: No polyuria, dysuria, and nocturia. Urinates about 4-5 times
daily about 100 - 200 ml per urination.
Musculoskeletal: No joint pain, no stiffness.
Peripheral Vascular: No intermittent claudication, no leg cramps.
Psychiatric: No nervousness, tension, depression, and memory loss.
Endocrine: No heat or cold intolerance, no excessive sweating, no
polydipsia and polyphagia.

VIII. PHYSICAL EXAMINATION

General survey:
The patient was examined alert and cooperative appearing to be slightly tired
in a sitting position. Attached to an O2 delivery system via nasal cannula at 4LPM .
She is an ectomorph and is oriented to time, place, and person. Afebrile, and in
mild cardiopulmonary distress as evidenced by the use of accessory muscles with
ventilation and with supraclavicular retractions.
Vital Signs:
Temp:
BP: 120/80 mmHg (Right arm and left arm)
PR: 84 bpm
RR: 26cpm
BMI:
Integument:
Skin is fair in complexion. Non pruritic, 2-3 mm round to disc-shaped skin
lesions with scabs and slightly raised erythema and scaling are present on her
upper and lower extremities. No suspicious nevi, petechiae, or ecchymosis. With
good skin turgor. Nails slightly pale with good capillary refill. No clubbing, ridges,
breaks.

Head:
Skull is normocephalic/atraumatic. No lumps. With redness and scaling
present along the hairline. Has dandruff on scalp. Hair is average in texture and
black in color with even distribution. Face is symmetrical, pale looking with no
involuntary movements, edema, and masses.

Eyes:
Symmetrical eyebrows with evenly distributed hair. Anicteric sclera. Pale
conjunctiva. With adequate closure of the eyelids and normal outward projection
of the eyelashes. Corneal reflections on both eyes are symmetrical without
opacities. No scars and ulcerations. Iris fairly flat and casts no shadow when
lighted directly from temporal side. Pupils symmetrical with diameter of 3 mm,
equally round and reactive to light and accommodation. Intact visual fields. Full
EOM with no field cuts. Normal conjugate gazes. No nystagmus and lid lag. With
good convergence on both eyes.

Ears:
Symmetrical alignment. Firm pinnae. No pain. Intact tympanic membranes and
canals. Hearing acuity intact.

Nose and Sinuses:

Pinkish and dry nasal mucosa. No abnormal discharge. Nasal septum midline.
Turbinates red and not inflamed. No lesions. No tenderness over sinuses.

Mouth and Throat:

No halitosis. Lips symmetrical, slightly pale, and dry, with no lesions. Intact
oral mucosa. Gums pinkish with no bleeding. Intact hard palate. Teeth complete,
some with dental carries. Tongue is pinkish and smooth with symmetric
protrusion. Lingual frenulum and uvula midline. Pharynx without exudates.
Tonsils not inflamed. With oral aphthae.

Neck:
Neck supple. No palpable lymph nodes. Trachea midline and moves with
deglutition. Thyroid glands not palpable. No carotid bruits.

Chest and Lungs:

Inspection: with anteropostero diameter slightly equal to the
transverse thoracic diameter. No lagging upon
expiration.
Palpation: tenderness over the right upper posterior chest. With
symmetrical chest expansion. Normal tactile fremitus on
both sides.
Percussion: Resonant on both lung field.
Auscultation: inspiratory crackles heared over right upper, middle and basal
lung fields and left lower lung field. Coarse wheezing heared
over both right and left upper anterior chest field.Decreased
breathsounds heared over left upper posterior lung field.

Heart:
Carotid artery: Carotid artery upstrokes are brisk on both sides, without
bruits.
Heart:
Inspection: No precordial bulging and visible pulsations. Point of
maximal impulse is not visible.
Palpation: The point of maximal impulse (PMI) is tapping at MCL
along the 5th ICS. No palpable heaves. No thrills nor
heaves.
Auscultation: Late diastolic sound greatly heard over Right sternal
border. Apical beat synchronous with carotid
pulsations. No S3 and S4. No pericardial rubs. No
murmurs.
Abdomen:
Inspection: Abdomen is symmetrical and full. No lesions, visible
pulsations, masses, and peristalsis.
Palpation: Soft and non-tender. No palpable masses or
hepatosplenomegaly. Spleen and kidneys not felt. No
costo-vertebral angle (CVA) tenderness.
Percussion: Tympanitic on all quadrants. Liver span approximately
7 cm.
Auscultation: Normal bowel sounds.
 Extremities:
Equal in size and length, no deformities, no trauma, no visible
pulsations, no varicosities. No edema on both lower extremities. Full peripheral
pulses, grade +2.

IX. NEUROLOGIC EXAMINATION

A. Mental Status
Patient appears slightly tired, and cooperative. She is well-groomed with
affect within normal range. Speech is clear, fluent with good repetition,
comprehension, and naming. Thought processes are coherent, insight is good.
Calculations intact.

B. Cranial Nerves
CN I Intact
CN II Pupils are 3mm and reactive to light and accommodation.
Normal direct and consensual reflexes.
CN III, IV, VI EOM intact with good convergence.
CN V Facial sensation intact to pinprick. Corneal responses intact.
CN VII Facial symmetric with normal eye closure and smile.
CN VIII Intact.
CN IX and X Palate elevates symmetrically. Phonation normal.
CN XI Intact head turning and shoulder shrug.
CN XII Tongue midline with normal movements and no atrophy.

C. Motor function
Muscle strength is full on upper extremities with normal muscle bulk and tone.
Muscle strength on lower extremities are weak 3/5 bilaterally.

D. Sensory
On upper extremities, light touch, pinprick, and position sense are intact. Two-
point discrimination are normal. On lower extremities, light touch is not well sensed
and sensation to pinprick is decreased. Two-point discrimination is impaired, patient
misses to recognize dull from sharp.

E. Reflexes
Biceps Triceps Brachioradialis Knee Ankle Plantar
R 2+ 2+ 2+ 2+ 2+ 2+
L 2+ 2+ 2+ 2+ 2+ 2+

Pathologic Reflexes
(-) Babinski reflex
(-) Ankle clonus

G. Cerebellar
 RAMs and fine-finger movements intact. No abnormal extraneous movements.
Posture is normal.

H. Meningeal Signs:
(-) Brudzinskis sign
(-) Kernigs sign

I. Autonomics:
No bladder or bowel incontinence.

X. DIFFERENTIAL DIAGNOSIS

Salient Features:

HPI findings Past medical

Demographics PE findings
Hx findings
60 years old * Chronic * * coarse wheezing
Female productive cough * inspiratory
Farmer * progressive crackles
exertional dyspne
* easy fatiguability
*orthopnea

RISK FACTORS

* Chronic smoking History

* nagtatap-ong

* uses fire wood for cooking

PERTINENT NEGATIVES

*no edema

* no hemoptysis

* no clubbing

* no colds

* no cyanosis
DIAGNOSIS

COPD- Moderate risk

Reasons for consideration:

*Chronic productive cough
* progressive exertional dyspne
* easy fatiguability
*orthopnea
* Chronic smoker
* inpiratory crackles
* coarse wheezing

Differential Diagnosis

Diseases Reasons for Ruling In Reasons for Ruling Out

Productive cough, Dyspnea, Fatigue, No night sweats, no

Pulomonary TB sudden weight loss chills, no loss of
appetite

Community acquired Productive cough, low grade fever No mental status

pneumonia upon onset,Fatigue changes
 No effort related
Exertional dyspnea, orthopnea , syncope, no
Congestive heart disease
inspiratory crackles abdominal pain and
acites, no cyanosis

XI. LABORATORY and DIAGNOSTICS:

1. Laboratory Studies
Arterial blood gas provides the best clues as to acuteness and severity. In general, renal
compensation occurs even in chronic CO2 retainers (ie, bronchitics); thus, pH usually is near
normal. Generally, consider any pH below 7.3 a sign of acute respiratory compromise.
Serum chemistry These patients tend to retain sodium. Diuretics, beta-adrenergic agonists, and
theophylline act to lower potassium levels; thus, serum potassium should be monitored
carefully. Beta-adrenergic agonists also increase renal excretion of serum calcium and
magnesium, which may be important in the presence of hypokalemia.
CBC count CBC count may reveal polycythemia.

2. Spirometry

-Post-broncho-dilator FEV1/FVC<0.70 confirms presence of persistent airflow limitation

-FEV1, FEV1/FVC and all other measures of expiratory airflow are reduced
-TLC,FRC and RV may be increased indicating air trapping
-DLCO may be reduced

3. Chest radiograph

-low flattened diaphragms, increase in the volume of retrosternal airspace

(hyperinflation)
-hyperluscent lung zones with possible bullae formation and diminished vascular
markings
4. Sputum exam.
To rule out TB and other respiratory infections

5. Pulse oximetry
 -to evaluate a patients oxygen saturation and need for supplemental oxygen therapy
-should be used to assess all stable patients with FEV 1<35% predicted or with clinical
signs suggestive of respiratory failure or right heart failure
-If peripheral saturation is <92%, arterial blood gases should be assessed

IV. Arterial Blood Gas (ABG)

resting or exertional hypoxemia

Increased alveolar-arterial oxygen tension gradient
In long-standing disease, may have chronically increased arterial PaCO 2 but metabolic
compression (increased HCO3) maintains pH near normal

XII. TREATMENT:

Pharmacologic Management of Exacerbations

1. OXYGENATION

Initial therapy should focus on maintaining oxygen saturation at 90 percent or higher. Oxygen
status can be monitored clinically, as well as by pulse oximetry. Oxygen supplementation by
nasal cannula or face mask is frequently required.

2. BRONCHODILATORS

Inhaled beta2 agonists should be administered as soon as possible during an acute

exacerbation of COPD. Use of a nebulizer to provide albuterol (Ventolin) or a similar agent with
saline and oxygen enhances delivery of the medication to the airways. 28

Orally administered beta2 agonists have more side effects than inhaled forms. Hence, oral
agents generally are not used to treat exacerbations of COPD.

3. ANTICHOLINERGICS

Compared with beta2 agonists, inhaled anticholinergics such as ipratropium (Atrovent) provide
the same or greater bronchodilation. These agents have been shown to be beneficial in
patients with COPD.12 Anticholinergics can be delivered by nebulizer or metered-dose inhaler.
In inhaled forms, anticholinergics have few adverse effects because of minimal systemic
absorption. Use of a combination product such as ipratropium-albuterol (Combivent) may
simplify the medication regimen, thereby improving compliance.

4. ANTIBIOTICS

Antibiotic therapy has been shown to have a small but important effect on clinical recovery and
outcome in patients with acute exacerbations of chronic bronchitis and emphysema. 30 Therefore,
antibiotic administration should be considered at the beginning of treatment for exacerbations
of COPD.
Initial outpatient management may include orally administered doxycycline (Vibramycin),
trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS) or amoxicillin-clavulanate potassium
(Augmentin).12 Patients who are older than 65 years of age or have more frequent exacerbations
(four or more episodes per year) may need an augmented penicillin or a fluoroquinolone.

Treatment for Stable COPD

NONPHARMACOLOGIC INTERVENTIONS

Patients with COPD should be encouraged to adopt and maintain a healthy lifestyle. Regular
exercise should be promoted, and nutritional management should be provided. Patients who
smoke should stop smoking. Smoking cessation is the most important, and probably the most
difficult, factor in preventing or treating COPD.

PHARMACOLOGIC INTERVENTIONS

Pharmacologic interventions used in the treatment of stable COPD include essentially the same
medications for the management of acute exacerbations of chronic bronchitis and emphysema

Treatment with orally administered corticosteroids for two to four weeks has been correlated
with a 20 percent or greater improvement of the baseline FEV1 in patients with COPD. 40
However, no current evidence is available on the long-term effects of steroid therapy on lung
function.

Annual influenza immunization is recommended for patients with COPD. Pneumococcal vaccine
should be given at least once, with consideration of re-vaccination every five to 10 years

References: