LEAVE ME

BREATHLESS
Earl Karyl F. Galvez, M.D.
PCGH level 1 Resident
Objectives:

General Objective:
• To discuss a case of a 66-year-old male presenting with SHORTNESS OF
BREATHING

Specific Objectives:
1. To formulate a diagnosis based on the patient’s history and physical
examination, and confirmed by different laboratory results.
2. To provide a therapeutic plan for the patient’s clinical manifestations and
current health condition.
3. To present a concept map associating the patient’s clinical findings and
2
the manifestations in the patient’s disease.
 IDENTIFYING DATA

CHIEF COMPLAINT:

Patient: CR
Age/Gender: 66 / Male
Residence: PASIG CITY SHORTNESS OF
Relationship Status: Married
Religion: Roman Catholic BREATHING
Admission: 1ST TIME

3
HISTORY OF PRESENT ILLNESS
1 WEEK PTC
● On and off onset shortness of
breathing 3 DAYS PTC
● Dyspnea in exertion
● No associated symptoms of (+) Occasional cough
fever, nausea and vomiting, (+) Shortness of breath
cough (+) Difficulty of
● Patient took salbutamol neb breathing
q8 and symbicort mdi 2 puff
bid
● No consultation was done. 4
HISTORY OF PRESENT ILLNESS
Few hours PTC

(+) Non-productive cough

(+) Shortness of
Breathing
(+) Difficulty of
Breathing
5
PAST MEDICAL HISTORY

● Known Hypertensive since 2021 (losartan 100mg /tab OD)

● Known Asthmatic since 30 years old (salbutamol neb and symbicort MDI)

● PTB Confirmed (2022); completed PTB regimen

6
PAST MEDICAL HISTORY
● BAIAE/Lung infection (Dec 2021)
● S/P intubated at PCCH

● BAIAE/ COPD (Dec 2022)

● PCGH ER

7
FAMILY MEDICAL HISTORY
Both Parents: No Comorbidities such as:
Hypertension
DM
Bronchial asthma
Thyroid diseases
Kidney diseases
PTB or lung diseases
No other malignancies

8
PERSONAL AND SOCIAL HISTORY

● Smoker 1 pack/day= 30 pack per year

●Heavy beverage drinker 3x a week
●No illicit drug use

9
 REVIEW OF SYSTEM

Constitutional: (-) weight loss, (-) fever, (-) chills

Skin: (-) excessive sweating, (-) jaundice, (-) cyanosis

Eyes: (-) pain, (-) blurring of vision, (-) excessive lacrimation, (-) photophobia

Ears: (-) pain, (-) deafness, (-) tinnitus, (-) discharge

Nose and Sinuses: (-) change in smell, (-) epistaxis, (-) nasal obstruction, (-) pain around paranasal sinuses

Mouth and Throat: (-) Toothache, (-) Gum bleeding, (-) disturbances in taste, (-) sore throat, (-) hoarseness

Neck: (-) limitation of movement, (-) pain

10
REVIEW OF SYSTEM
Cardiovascular System: (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea

Gastrointestinal System: (-) dysphagia, (-) diarrhea, (-) constipation

Genitourinary System: (-) dysuria, (-) urgency, (-) hesitancy, (-) hematuria, (-) incontinence

Extremities: (-) limitation of movement

Nervous System: (-) paralysis, (-) speech disorder, (-) numbness

Hematopoietic System: (-) bleeding tendencies, (-) pallor, (-) easy bruising

Endocrine System: (-) intolerance to heat, (-) excessive weight gain or loss, (-) polyuria, (-) polydipsia

11
PHYSICAL EXAMINATION
GENERAL SURVEY:
Conscious, coherent, oriented to time, place,
person; in respiratory distress

VITAL SIGNS
BP : 130/70 mmHg HT: 162.56 cms
HR : 110 bpm WT: 58kg
RR : 25 cpm BMI: 22.1 kg/m2 (Normal) :
O2sat : 97% at 2-3 LPM via
NC 12
PHYSICAL EXAMINATION
INTEGUMENTARY:
Color is brown, nail beds are pink and CRT < 2 seconds, no active dermatoses

HEAD:
Hair color is black. Scalp is clean. Head is normocephalic, symmetrical, no swelling, no
deformities, no tenderness and no masses. Temporal arteries are visible and palpable
with equal pulsations.
EYES:
Eyebrows are black, thin evenly distributed, no erythema and no lesions noted;
palpebral fissures symmetrical, eyelashes are thin, with outward direction of growth, no
matting, eyeballs are normally set, pale palpebral conjunctivae, anicteric sclerae, iris
are dark brown with regular contours, pupils are 2-3 mm equally reactive to light and
accommodation. No exophthalmos, enophthalmos and nystagmus on both eyes

13
PHYSICAL EXAMINATION
EARS:
Auricles are symmetrical and non-tender; auditory canals are patent, pink mucosa,
patent ear canal, intact tympanic membrane, no lesions and no discharge.

NOSE:
Nose is symmetrical, no alar flaring, patent vestibules, mucosa is pink, septum midline
and intact, no tenderness noted

MOUTH AND ORAL CAVITY:

Lips are symmetrical and dry, buccal mucosa and gums are pink and moist. Tongue isat
the midline and symmetrical. Hard and soft palates are pink, no lesions, uvula is at
midline. Pink pharyngeal walls. Tonsils are pink, not enlarged, with no exudates, no oral
ulcers.

14
PHYSICAL EXAMINATION
NECK:
Normal in size, supple, symmetrical, no neck vein engorgement, no mass, normal
muscle development and tone, trachea at midline, no palpable lymph nodes. No carotid
bruit appreciated. Thyroid gland is not visible and not palpable.

CHEST & LUNGS:

Skin is fair, no skin lesions, no dilated superficial blood vessels, bony thorax is
symmetrical and elliptical, symmetrical chest expansion, no retractions, no deformities,
no lagging, normal tactile and vocal fremitus, tight air entry, with occasional wheezes
both mid zone, crackles bilateral lower lung field, negative bronchophony,
egophony and whispered pectoriloquy.

HEART:
Adynamic precordium, no heaves nor thrusts, no palpable thrills. The apex beat is at the
5th intercostal space left midclavicular line, normal rate, regular rhythm. S1 best heard
at the apex, S2 best heard at the base. No S3 or S4. No murmurs appreciated

15
PHYSICAL EXAMINATION
ABDOMEN:
Abdomen is brown, flat, inverted umbilicus, no dilated superficial blood vessels, no
abnormal pulsations, no visible peristalsis and no visible mass; hyperactive bowel
sounds; no bruit heard over the epigastrium, right and left paraumbilical area; no
tenderness on all quadrants, non-palpable liver and spleen; tympanitic all over
EXTREMITIES:
No gross deformities, with full and equal pulses on all extremities, no edema, no
cyanosis

NEUROLOGIC EXAMINATION:
Cerebrum: GCS 15, conscious, coherent, oriented to time, place, person with intact
immediate, recent memory
Cerebellum:No nystagmus, no ataxia, negative Romberg’s test, no dysmetria, no
dysdiadochokinesia

16
PHYSICAL EXAMINATION
Cranial Nerves
CN I: Not assessed
Meningeal signs:
CN II: Pupils 2-3mm equally reactive to light
Negative nuchal rigidity, Brudzinski sign and Kernig sign
CN III, IV, VI: Intact extraocular muscles
CN V: Can clench teeth
Pathologic reflexes:
CN VII: No facial asymmetry can raise eyebrows equally
No Babinski reflex
CN VIII: intact gross hearing
CN IX, X: Uvula is at midline, (+) gag reflex
CN XI: Equal shoulder shrug, bilateral
CN XII: Tongue is at midline; no fasciculations

17
SALIENT FEATURES PMH:
● Asthma for more than 30years,
● Chronic Obstructive Pulmonary Disease since
Dec 2021
● PTB confirmed (6mos treated)

History:
1 wk PTC :
● Productive cough- whitish Personal and Social Hx:
phlegm ● Heavy alcoholic beverage drinker
● SOB on exertion
66 y/o ● 1 pack/day = 30 pack/year smoker
3 days PTC:
● Productive cough male
● SOB associated w/ DOB,
Few hrs PTC:
● Productive cough w/ SOB on
exertion associated w/ DOB
PE:
● RR: 25 cpm
● Pale palpebral conjunctiva
● Crackles bilateral lower lung field (B)
● Wheezes right mid zone

18
 Differential diagnosis

DIFFERENTIAL
DIAGNOSIS
19
 CHF
RULE IN RULE OUT
• 66year old male
• Productive to non productive (-) Neck vein distension
(-) Paroxysmal nocturnal dyspnea or orthopnea
cough (-) Cardiomegally
• (+) wheezes mid zone (-) Hepatojugular reflux
(-) acute pulmonary edema
• (+) crackles bilateral
• Known HPN for 3 years
• Previous 30 pack year smoker
• Previous alcoholic beverage
drinker CANNOT TOTALLY
• Atheromatous aorta RULE OUT

Framingham Criteria:
Minor criteria: Dyspnea on exertion
Bilateral minimal pleural effusion
20
 Pulmonary Tuberculosis
RULE IN RULE OUT
• 66year old male
• Productive to non productive (-) Afternoon fever
(-) Tachycardia
cough (-) hemoptysis
• (+) wheezes mid zone (-) weight loss
(-) Night sweats
• (+) crackles bilateral
• Known HPN for 3 years
• Previous 30 pack year smoker
• Previous alcoholic beverage CANNOT TOTALLY
RULE OUT
drinker
• (+) Family hx of asthma
• (+) Hx of PTB
21
 Bronchiectasis
RULE IN RULE OUT
• 66year old male (-) coughing of blood or mucus mixed of blood
• Productive to non productive (-) Fever
(-)clubbing of fingers
cough
• Shortness of breathing
• (+) wheezes mid zone
• (+) crackles bilateral
• Known HPN for 3 years
• Previous 30 pack year smoker CANNOT TOTALLY
• (+) Family hx of asthma RULE OUT

22
 INITIAL IMPRESSION

Asthma in acute Exacerbation

T/C Chronic Obstructive Pulmonary
Disease in Acute Exacerbation;
HASCVD; HTN stage 2 uncontrolled

23
CLINICAL
DISCUSSION
24
ER LEVEL

25
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(+) Shortness of breathing AS Paled Conjuctiva CBC pc, Serum electrolytes
(+) Productive cough, whitish in SCE +Crackles bilateral with BUN, CREA, ASL, ALT
color wheezes at both mid zones PT PTT
(-) DOB Globular abdomen, NT UA
(-) chest pain GNE (-) cyanosis and edema CXR
(-) Fever ECG 12 lead
Vital signs Troponin I
Bp 140/80 FBS, lipid profile
CR 111
RR 22
T 36.5
O2 sat 95 room air

26
CBC Chemistry Electrolyte
HGB 158 s
BUN 2.32
HCT 0.48 NA 141
PLT 176 CREA 88 K 3.5(L)
WBC 12(H)
CA 2.19
N 0.77(H) U/A
L 0.`4 CL 105 Color Yellow

MG 1.01(H) PH Slightly
TURBID
PT 13.8
ASL 50(H) SG 5.5
PTT 35.8
PUS 1-2
INR 1.01 ALT 41(H)
RBC 5-10
Prothrombin 98%
A.

Troponin I 116.1(H) 12.5(N)

27
CXR
4/29/23

Shows fibrosis in both upper

lobes

Apparent retoculonodular
densities in the right upper
lung are now morre apparent
for which PTB of
undetermined activity is not
ruled out

No other new active lung

infiltrates

28
Regular Sinus
rhyhm
Normal axis
No Hypertrophy
Left bundle
branch block
Lateral
ischemia

29
PLAN

Hook to 02 support @3-5 lpm via FM

IVF: Heplock

1.Budesonide + formeterol 160mcg/4.5 2 puff BID

2.ASA 80mg tab OD
3.Clopidigrel 75mg tab OD
4.Enoxaparin 0.3cc now then 0.6cc BID
5.Atorvastatin 80mg tab ODHS
6.Omeprazole 40mg tiv OD

30
CASE
DISCUSSION
31
 DEFINITION
➔ Disease state characterized by persistent respiratory symptoms
and airflow limitation that is not fully reversible

➔ Classic Definition: Presence of chronic airflow obstruction,

determined by spirometry, that usually occurs in the setting of
noxious environmental exposures (CIGARETTE SMOKING)
 COMPONENTS OF COPD
EMPHYSEMA CHRONIC BRONCHITIS SMALL AIRWAY
DISEASE

- Destruction and - Inflammation of airways - Narrowing of small

enlargement of the alveoli and - Chronic cough (at least 3 bronchioles which could be
airspaces distant to the months for 2 consecutive due to bronchospasm, mostly
terminal bronchiole years) and sputum production due to fibrosis, edema, and
obstruction due to secretions.
 CENTRILOBULAR PANLOBULAR PARASEPTAL
EMPHYSEMA EMPHYSEMA EMPHYSEMA

- MC associated with smoking -Common in patients with Alpha-1 - 10-15% of cases

- Prominent in upper lobes & Antitrypsin deficiency - Along pleural margins
superior segment of lower lobes -Lower lobes
PATHOGENESIS
RISK FACTORS
❏ Tobacco Smoke
❏ Indoor & Outdoor Air Pollution
❏ Occupational Exposures
❏ Genetic Factors - Alpha 1 Antitrypsin
Deficiency
❏ Age and Sex - 40s and Female
❏ Asthma and Airway hyperreactivity
❏ Infections
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

RISK FACTORS:
Tobacco smoking
(biomass fuel exposure, air pollution)

Ge
n
COPD ed
Ab etic a
r at
n
dev orma bnorm el e
el o l
p m l u n g a l i ti e cc ing
e nt s/ A ag

37
 Smoking, Silica, dust, pollutants

↑ Mucus Destruction of
production Cilia

Mucus Gland & Mucus Plug

Goblet cell
Hyperplasia
Airway
-Productive cough trappping
Airway narrowing -Expiratory
wheezing
↑ RISK OF PNEUMONIA
-V/Q Mismatch (↓
pO2/↑ pCO2)
-Polycythemia vera
AIRWAY HYPERINFLATION
-Respiratory
OBSTRUCTION acidosis
- Cyanosis
-JVP distention
CLINICAL PRESENTATION
➔ 3 most common symptoms:
◆Cough
◆Sputum Production
◆Exertional dyspnea

➔ Advanced COPD
◆Worsening dyspnea on exertion with increasing intrusion on the ability to
perform vocational or avocational activities
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
COUGH

SYMPTOMS

SPUTUM EXERTIONAL
PRODUCTION DYSPNEA

EXACERBATIONS**
● INCREASED DYSPNEA
○ INCREASED HYPERINFLATION AND GAS TRAPPING WITH REDUCE EXPIRATORY FLOW.
● HYPOXEMIA
○ THERES IS ALSO WORSENING OF VENTILATION PERFUSION ABNORMALITiIES

40
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

41
 PHYSICAL FINDINGS
EARLY STAGE COPD ADVANCED STAGE COPD SEVERE COPD

● Generally normal PE ● Cachexia ● Cyanotic

● Signs of active smoking ● “Hoover’s sign” - paradoxical ● “Tripod” position
(smoke odor, nicotine inward movement of rib cage ● “Barrel chest”
staining of fingernails) - upon inspiration ● Prolonged expiratory
for current smokers phase, may include
expiratory wheezing
● Enlarged lung volumes
REDOMINANTLY EMPHYSEMA
➔ Asthenic ➔ Physical Examination:
➔ Long history of exertional dyspnea
➔ Scanty mucoid sputum o Pink puffer
➔ Prominent accessory muscles o Barrel chest
o Tachypneic with purse lip
breathing
o Decreased breath sound
o Hyperresonant
o Cor pulmonale- late in the course
 PREDOMINANTLY BRONCHITIS
➔ Usually overweight
➔ Chronic cough
➔ Copious, purulent sputum ➔ Physical Examination: o Blue
(Less dyspneic)
bloater
oAccessory muscles not prominent
oCrackles, wheezes
oResonant
oCor pulmonale- early in the course
LABORATORY FINDINGS

Spirometry - Most important test to diagnose and stage

COPD (Gold standard)
- Reduction in FEV1 and FEV1/FVC (<0.7)

Arterial - Important component of the evaluation of

Blood Gas patients presenting with symptoms of an
exacerbation
- May demonstrate resting or exertional
hypoxemia
- Respiratory acidosis
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

46
2019, COPD GOLD
LABORATORY FINDINGS
Chest X-ray - May assist in the classification of the type of
COPD
- Emphysema - obvious bullae, paucity of
parenchymal markings, or hyperlucency

Chest - Current definitive test for establishing the

computed presence or absence of emphysema, the
tomography pattern of emphysema, and the presence of
significant disease involving medium and large
(CT) scan
airways
LABORATORY FINDINGS

Alpha-1 Antitrypsin - Recent guidelines have suggested testing for

deficiency (AATD) α1AT deficiency in all subjects with COPD or
asthma with chronic airflow obstruction
Screening

Complete Blood Count - For evaluation of eosinophil count in patients

prescribed with ICS
 ASSESSMEN
T
Goals DETERMINE:

1.Level of airflow limitation

2.Impact of disease on patient’s health status
3.Risk of future events (exacerbations, hospital admissions, or death)
52
TREATMENT
INTERVENTON
S
Pharmacotherapy
➔ An$bio$cs

➔ Alpha-­‐1 an$trypsin augmenta$on therapy

➔ Vaccina$on
NONPHARMACOLOGIC THERAPIES
Pulmonary - Exercise, education, breathing exercises, and psychosocial and
Rehabilitation nutritional counseling
- Improve health-related quality of life, dyspnea, exercise capacity and
reduce rates of hospitalization over a 6- to 12-month period

Lung Volume - Surgery to remove the most emphysematous portions of lung

Reduction - Patients with upper lobe–predominant emphysema and a low post-
Surgery rehabilitation exercise capacity are most likely to benefit from LVRS

Lung - Candidates for lung transplantation should have very severe airflow
Transplantation limitation, severe disability despite maximal medical therapy, and be
free of significant comorbid conditions
Approach to:

Asthma COPD overlap Syndrome (ACOS)

83
 ASTHMA COPD ACOS

Asthma is a heterogeneous Chronic obstructive pulmonary dis Asthma-

disease, usually characterized by ease (COPD) is a common, preve COPD overlap is characterized by
chronic airway ntable and persistent airflow limitation with s
inflammation. It is defined by the h treatable disease that is characteri everal
istory of respiratory symptoms suc zed by persistent respiratory symp features usually associated with a
h as wheeze, toms and sthma and several features usuall
y associated with
together with variable expiratory ai by significant exposure to noxious COPD. Asthma-
rflow limitation. [GINA 2017] particles or gases. [GOLD 2017] COPD overlap is therefore identifi
ed in clinical practice by the

This is not a definition, but a descr

iption for clinical use, as asthma-
COPD overlap
includes several different clinical p
henotypes and there are likely to b
e several

84
 STEPWISE APPROACH TO DIAGNOSIS OF PATIENTS WITH

RESPIRATORY SYMPTOMS

STEP 1: Does the patient have chronic airways disease? STEP 2. The syndromic diagnosis of asthma, CO
PD and asthma- COPD overlap in an adult patient

Clinical History

Physical examination
Assemble the features that favor a diagnosis of asthma or of
Radiology COPD

Compare the number of features in favor of a diagnosis of

asthma or a diagnosis of COPD

Consider the level of certainty around the diagnosis of asthma

or COPD, or whether there are features of both suggesting
asthma-COPD overlap

85
86
87
88
89
90
91
92
93
Ward Level

94
SALIENT FEATURES PMH:
● Asthma for more than 30years,
● Chronic Obstructive Pulmonary Disease since
Dec 2021
● PTB confirmed (6mos treated)

History:
1 wk PTC :
● Productive cough- whitish Personal and Social Hx:
phlegm ● Heavy alcoholic beverage drinker
● SOB on exertion
66 y/o ● 1 pack/day = 30 pack/year smoker
3 days PTC:
● Productive cough male
● SOB associated w/ DOB,
Few hrs PTC:
● Productive cough w/ SOB on
exertion associated w/ DOB
PE:
● RR: 25 cpm
● Pale palpebral conjunctiva
● Crackles bilateral lower lung field (B)
● Wheezes right mid zone

95
 INITIAL IMPRESSION

Asthma in acute Exacerbation

R/O Chronic Obstructive Pulmonary
Disease in Acute Exacerbation;
HASCVD; HTN stage 2 uncontrolled

96
SUBJECTIVE OBJECTIVE DIAGNOSTIC

(+) dyspnea AS Paled Conjuctiva ABG

(+) Shortness of breathing SCE +crackles bilateral with Repeat CXR
(+) productive cough, wheezes at both mid zones MTB gene xpert
whitish in color Globular abdomen, NT Sputum GSCS
GNE (-) cyanosis and Repeat Serum K
(-) DOB edema FB
(-) chest pain Lipid profile
(-) Cough Vital signs 2decho with doppler
Bp 140/80
CR 93
RR 22
T 36.9 WARD IMPRESSION
O2 sat 98 at 2-3lpm NC 1. BAIAE
2. R/O PTB
3. HTN STAGE 2
4. HASCVD

2020 Global Initiative for Chronic Obstructive Lung Disease 97

Lipid profile 5/1/23 Repeat S. K 3.9
Fbs 6.02

Cho 5.9 (INC) ABG

Tg 1.19 PH 7.47
P02 97.7
Hld 3.0 (INC)
Pco2 39.5
Ldl 2.5
Hco3 28.0

Sputum CS GS
No pathogen Gram negative 3-4
PMN 1-2

MTB MTB not detected

98
5/4/23

Bilateral upper
lobe opacities
more on the
right

Pulmonary
vasculature is
normal

Right sulcus
remain
shadow

Left sulcus is
now better
delineated

99
WARD MANAGEMENT

1. Hook to 02 support @2-3 LPM via FM

2. IVF: Heplock

3. Hydrocortisone 100mg TIV q8

4. Salbutamol + ipratropium neb q8
5. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
6. Montelukast 10mg tab OD
7. Ceftriaxone 2gm TIV OD
8. Azithromycin 500mg tab OD x 5 days
9. Nac 600mg Tab BID
10. Losartan 100mg OD
11. ASA 80mg tab OD
12. Clopidogrel 75mg tab OD

100
3rd day of HOS

101
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(+) minimal productive cough, AS Paled Conjuctiva Repeat CBC pc
whitish in color SCE +crackles bilateral with For Spirometry Test
wheezes at both mid zones Still for 2decho with doppler
(-) DOB Globular abdomen, NT
(-) chest pain GNE (-) cyanosis and edema
(-) Cough WARD IMPRESSION
(-) dyspnea Vital signs 1. BAIAE vs COPD
(-) Shortness of breathing Bp 130/70 2. HTN STAGE 2
(-) Fever CR 82 3. HASCVD
RR 20
T 36.9
O2 sat 98 at 1-2 lpm NC

102
Repeat CBC PC
Hgb 147
hct 0.44
Plt 228
WBC 11.3 (12)
N 0.68 (0.75)

103
WARD MANAGEMENT
1. Diet low salf, low fat
2. IVF: Heplock
3. 02 support PRN

3. Decrease Hydrocortisone 100mg TIV q12

4. Salbutamol + ipratropium neb q8
5. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
6. Montelukast 10mg tab OD
7. Losartan 100mg OD
8. ASA 80mg tab OD
9. Clopidogrel 75mg tab OD
10. Ceftriaxone 2gm TIV OD
11. Nac 600mg Tab BID

Advised for deep breathing exercises

Moderate high back rest
Chest physiotherapy instructed
Refer to Dietary for Nutritional regimen

104
6th day

105
SUBJECTIVE OBJECTIVE DIAGNOSTIC

AS Paled Conjuctiva Repeat CXR PA

(-) DOB SCE minimal wheezes at Repeat Serum K and Na
(-) chest pain both mid zones, no crackles
(-) Cough Globular abdomen, NT For Spirometry Test
(-) dyspnea GNE (-) cyanosis and Still for 2decho with doppler
(-) Shortness of breathing edema
(-) Fever
(-) productive cough Vital signs WARD IMPRESSION
Bp 120.80 1. BAIAE vs COPD
CR 80 2. HTN STAGE 2
RR 20 3. HASCVD
T 36.5 4. Hypokalemia
O2 sat 99 at room air

CBG range from 110-135

mg/dl

106
Serum Electrolytes
Sodium 141
Potassium 2.3

Repeat CBC PC
Hgb 146
hct 0.44
Plt 211
WBC 8.5 (N)
N 0.70

107
5/10/23

NO significant change is
seen in the fibronodular
densities in both upper
lungs

Blunting of the right

costophrenic sulcus likelty
representing pleural
thickening

The rest of the chest

structure shows
unremarkable

108
WARD MANAGEMENT

1. Diet low salf, low fat

2. IVF: Heplock
3. 02 support PRN

3. Hydrocortisone 2decho
100mg withTIV
doppler
q12
4. Salbutamol + ipratropium neb q8
5. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
6. Montelukast 10mg tab OD
7. Losartan 100mg OD
8. ASA 80mg tab OD
9. Clopidogrel 75mg tab OD
10. Ceftriaxone 2gm TIV OD
11. Decrease Nac 600mg Tab BID to OD
12. Kcl drip 10meqs kcl + 90n NSS x 2hours x 3 cycles

Advised for deep breathing exercises

Moderate high back rest
Chest physiotherapy instructed
Refer to Dietary for Nutritional regimen
109
8th day of HOS

110
SUBJECTIVE OBJECTIVE DIAGNOSTIC

(-) DOB AS Paled Conjuctiva For Spirometry

(-) chest pain SCE no wheezes, no
(-) Cough crackles 2decho with Doppler
(-) dyspnea Globular abdomen, NT awaiting result
(-) Shortness of GNE (-) cyanosis and
breathing edema WARD IMPRESSION
(-) Fever 1. BAIAE vs COPD
(-) productive cough Vital signs 2. HTN STAGE 2
Bp 120/70 3. HASCVD
CR 85 4. Hypokalemia-
RR 21 resolving
T 36.5
O2 sat 99 at room air

111
Serum electrolytes Post Correction
Serum Na 138
Serum K 3.9

112
WARD MANAGEMENT

1. Diet low salf, low fat

2. IVF: Heplock
3. 02 support PRN

3. Hydrocortisone 50mg TIV q12

4. Salbutamol + ipratropium neb q8
5. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
6. Montelukast 10mg tab OD
7. Losartan 100mg OD
8. ASA 80mg tab OD
9. Clopidogrel 75mg tab OD

10. D/C KCL drip 10meg + 90cc PNSS x 2hrs x 3 cycles

11. D/C Ceftriaxone 2gm TIV OD
12. D/C Nac 600mg Tab OD

Advised for deep breathing exercises

Moderate high back rest
Chest physiotherapy instructed
Refer to Dietary for Nutritional regimen
113
10TH
OF HOS

114
SUBJECTIVE OBJECTIVE DIAGNOSTIC

(-) DOB AS Paled Conjuctiva Schedule for Spirometry

(-) chest pain SCE no wheezes, no at TMC on may 14,
(-) Cough crackles 2023
(-) dyspnea Globular abdomen, NT
(-) Shortness of GNE (-) cyanosis and
breathing edema WARD IMPRESSION
(-) Fever 1. BAIAE overlap
(-) productive cough Vital signs COPD-controlled
Bp 120/80 2. HTN STAGE 2-
CR 76 controlled
RR 20 3. Hypokalemia-
T 36.7 resolving
O2 sat 98 at room air 4. HASCVD

115
WARD MANAGEMENT

1. Diet low salf, low fat

2. IVF: Heplock
3. 02 support PRN

3. Spiriva respirant 1 cap OD

4. Salbutamol + ipratropium neb q8
5. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
6. Montelukast 10mg tab OD
7. Losartan 100mg OD
8. ASA 80mg tab OD
9. Clopidogrel 75mg tab OD

Advised for deep breathing exercises

Moderate high back rest
Chest physiotherapy instructed
Refer to Dietary for Nutritional regimen

116
MGH

117
SUBJECTIVE OBJECTIVE DIAGNOSTIC

(-) DOB AS Paled Conjuctiva Re-Schedule for

(-) chest pain SCE no wheezes, no Spirometry after 1
(-) Cough crackles month post discharge
(-) dyspnea Globular abdomen, NT
(-) Shortness of GNE (-) cyanosis and
breathing edema WARD IMPRESSION
(-) Fever 1. BAIAE overlap
(-) productive cough Vital signs COPD-controlled
Bp 130/80 2. HTN STAGE 2-
CR 76 controlled
RR 20 3. Hypokalemia-
T 36.7 resolving
O2 sat 98 at room air 4. HASCVD

118
TAKE HOME MED

1. Salbutamol + ipratropium neb q8 PRN

2. Budesonide + formeterol 160mcg/4.5mcg 2 puff BID
3. Spiriva respirant 1 cap OD
4. Montelukast 10mg tab OD
5. Losartan 100mg OD
6. ASA 80mg tab OD
7. Clopidogrel 75mg tab OD

Advised for deep breathing exercises

Moderate high back rest
Chest physiotherapy instructed
Refer to Dietary for Nutritional regimen

119
 Final Diagnosis
ASTHMA IN ACUTE EXACERBATION
OVERLAP COPD;
HYPERTENSION STAGE 2-
CONTROLLED;
HASCVD

120
 66/M + 30 pack years history of smoking

Hypertrophy and hyperplasia Ciliary dysfunction

Epithelial CD8+ T Rtp801
of mucus glands and goblet ● ↓ Ciliary beat Macrophages
cells IP-10 Ceramide
cells ● Cilia shortening

Mucus hypersecretion
TGFβ TNF𝛂
Chemokines (+) IP-10 (-) mTOR
FGF IL-8

Productive
cough Accumulation of More
CTGF Neutrophils
mucus in the airways macrophages Apoptosis
Ronchi
Impaired
Fibrosis of Elastase/
macrophage
Wheezing Airway narrowing small airways MMP12
intake

Ineffective
Elastin repair
degradation
121
 Elastin
degradation

Airway ↑ Lung Airway narrowing

↓ Lung recoil
collpase complaince

AIR Hypoxemia
TRAPPING
Difficulty of breathing
V/Q mismatch Tachypnea: 24 cpm
O2 sat: 63%
↑ End Expiratory
Volume
Hypercapnia

↑ Dilate
respiratory
acinus

Elliptical chest/
Barrel chest 122
 TAKE HOME MESSAGE

• Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease
that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway
and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
• The most common respiratory symptoms include shortness of breath, cough and/or sputum
production. These symptoms may be under-reported by patients.
• The main risk factor for COPD is tobacco smoking. Host factors predispose individuals to develop
COPD. These include genetic abnormalities, abnormal lung development and accelerated aging.
• COPD may be punctuated by periods of acute worsening of respiratory symptoms, called
exacerbations.
• In most patients, COPD is associated with significant concomitant chronic diseases, which increase
its morbidity and mortality.
123
References:
● Pahal, P; Hashmi, M; Sharma, S., ( August 2021) StatPearls: Chronic Obstructive Pulmonary
Disease Compensatory Measures, from https://www.ncbi.nlm.nih.gov/books/NBK525962/
● Koo, H., Kang, H. et al (July 2017) Tuberculosis and Respiratory Disease: Systemic White Blood
Cell Count as Biomarker Associated with Severity of Chronic Obstructive Lung Disease, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526959/#
● Barnes PJ. The cytokine network in asthma and chronic obstructive pulmonary disease. The Journal of
Clinical Investigation. 2008 Nov;118(11):3546-3556. DOI: 10.1172/jci36130. PMID: 18982161; PMCID:
PMC2575722.
● Wiener, C., Fauci, A. S., Braunwald, E., Kasper, D. L., Hauser, S. L., Longo, D. L., Jameson, J. L., &
Loscalzo, J. (2008). Harrison's principles of Internal Medicine, self-assessment and board review.
McGraw Hill

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