SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Alcantara, Edna

SUBMITTED BY: de Leon, Jan GilDe los Santos, RosheilDitti, Fatimah Al-ZahraDivinagracia, Joshua Luke

I. REPRESENTATIVE CASE

Identifying data: A case A.T., 72 years old, male, married, farmer, Filipino, Catholic from Sto. Nio, Tanjay admitted for the first time.

Chief complaint: Dyspnea and Fever

History of Present illness:2 weeks PTA, patient complained of fever occurring day and night which was reported to be on and off, temperature was not taken. There was no medication taken and noticed associated fatigue. He was having difficulty of breathing on exertion. But no cough noted.

10 days PTA, patient was brought to a private doctor and was prescribed with Mefenamic Acid, Amoxicillin and unrecalled medicine for his complains and he only took the medication for 2 days. But the symptoms still persisted.

1 week PTA, patient seek another opinion from a local doctor and was prescribed with salbutamol which was taken in the morning and afternoon with temporary relief. He took the medication for 5 days and came back for follow up check up.

1 day PTA, he was advised for chest X-Ray and after the results taken, patient was referred to be admitted to NOPH.

Past Medical History:Immunization is completed. Minor surgery on the distal end of the right 2nd finger after accidentally cutting the finger from his work in bakery. No recalled diagnosed disease. No recalled allergies.

Family History:No recalled medical problem on his family. Wife has long standing hypertension with maintenance medication. Has 8children and the 2nd child died from post part up complication and the 8th child died in his younger years.

Personal Social History:He is a 55 pack years and also chews tobacco leaf. He is an admitted alcohol beverage drinker consuming 1-2 flats per week. He sleeps at 10pm- 4am. He doesnt have any exercise. He is currently living with wife and a son.

REVIEW OF SYSTEMSPHYSICAL EXAMINATION

General Survey: (+) fatigue and weightlossSkin: (-) rashes, sores, itching, and color changesHEENT: (+) headache and visual haziness, doesn't wear eyeglasses; (-) ear discharges, infection, earaches and tinnitus; (+) pain on sinuses sometimes, (-) nosebleeds, (-) toothaches, bleeding gums and sorethroatNeck: (-) neck pain and lumpsRespiratory: (+) cough with small amount of white phlegm noted, (-) hemoptysis (+) dyspnea Cardiovascular: (-) Chest pain, HPN, and palpitationsGIT: (-) pain on swallowing; bowel movement 3x/day; (-) nausea and vomitingGUT: (-) polyuria; urinates 3x/day; (+) pain on urination with hematuriaGenital: Started sexual activity after marriage (1965); he now stopped sexual activity with wife; (-) Genital discharges, and painPeripherals: (-) Pain, claudication and edema; (+) blue discoloration of lower extremities after walkingMusculoskeletal: (-) Muscle and joint pains, arthritis, inflammation and stiffnessNeurologic: (-) Fainting, seizures,paralysis and loss of sensationHematologic: (-) Anemia and easy bruising/bleedingEndocrine: (-) polyuria, excessive thirst and heat or cold intolerancePsychiatric: (-) Memory change, nervousness and depression

LABORATORY & DIAGNOSTIC TESTS

LABORATORY TESTRATIONALECOST

Complete Blood Count

CBC serves as a baseline data to determine the extent of the disease of the patient status and to help in the management of the patient. There is an increased RBC count in patients with COPD to compensate with the lack of oxygen in the body. CBC also helps diagnose conditions, such as anemia and infection.Php220

Electrolytes Na+ K+

Patients with chronic obstructive pulmonary disease have a slower rate of potassium exchange and an increase in residual sodium composed of intracellular sodium and exchangeable bone sodium.Too much sodium and salt (sodium chloride) can cause the body to retain too much fluid that makes breathing more difficult. The excess fluid in the blood makes the heart work harder, which can damage it over time. And also, sodium and potassium provides information on kidney function.Php290

ECGECG should be done to exclude cardiac causes of dyspnea.Php660

Arterial Blood GasABG analysis provides the best clue as to acuteness and severity of the disease exacerbation (COPD). Patients with mild COPD have mild to moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia may develop

SpirometrySpirometrymeasures the amount of airflow obstruction present. Normally, 7580% of the FVC comes out in the first secondand aFEV1/FVC ratioof less than 70% in someone with symptoms of COPD defines a person as having the disease.

Sputum G/SIn persons with stable chronic bronchitis, the sputum is mucoid and macrophages are the predominant cells. With an exacerbation, sputum becomes purulent because of the presence of neutrophils. The pathogens cultured most frequently during exacerbations areStreptococcus pneumoniaeandHaemophilus influenzae.Moraxella catarrhalisis also a common organism, andPseudomonas aeruginosacan be seen in patients with severe obstruction.

Chest X-rayA chest x-ray may offer early clues to other important diagnoses, such as pneumonia, CHF, pleural effusion, aortic dissection, and pneumothorax.Php270

THERAPEUTIC MANAGEMENT

LIST OF PROBLEMSTHERAPEUTIC OBJECTIVES

1. Dyspnea2. Fever3. Fatigue4. Weightloss5. Cough1. To identify and treat underlying cause of the disease2. To ensure adequate oxygenation3. To return the vital sign parameters to normal4. To provide adequate nutrition and hydration5. To restore/improve body strength 6. To prevent complications

ADVICE AND INFORMATIONNON-PHARMACOLOGIC MANAGEMENT

1. Educate patient and family on his present health condition, pathophysiology and the complications which may result if left untreated.

2. Impart to the patient the information about his nutritional needs and medications to achieve compliance.

3. Impart to the patient the importance of good nutrition with regards to his condition. 4. Teach the patient breathing techniques such as pursed-lip breathing help reduce respirations while improving the expiratory phase.

5. Advise patient to do energy-conservation techniques. Pace activities, take frequent rests, use assistive devices, and break activities into smaller tasks to help reduce dyspnea development.

6. Impart to the patient the proper position which is the tripod position, in which the patient sits or stands leaning forward with the arms supported, forces the diaphragm down and forward and stabilizes the chest while reducing the work of breathing.

7. Advice the patient to take his medications regularly to prevent complications1. Admit patient.2. Ensure adequate oxygenation, with target oxygen saturation at 90-92%. Start with low flow oxygen at 1-2 liters per minute only. Watch out for CO2 retention.3. Ensure patients hydration. Monitor Intake and Output.4. Diet: NPO if patient is dyspneic5. Position patient in high or semi-fowlers position to facilitate easy breathing.