Copd

IDENTIFYING DATA
SL DOB: Nov. 1, 2017
Cabantan St. Bo, Luz, Cebu City

69 yo
Source of Info: Parents

male
Reliability: 90%
Married
Fever and Cough
CHIEF COMPLAINT
Dyspnea
HISTORY OF PRESENT ILLNESS
• Rhinorrhea w/ clear nasal discharge & nonproductive
6 cough
DAY • No associated symptoms. No interventions done.
S
• Persistence thus sought consult with a general physician

• Cefaclor 50mg/mL 1.3 mL TID (28 mkD) x 4 days
5 • Phenylpropanolamine 6.25mg/mL 0.6 mL (0.5 mkd) TID x 4 days
DAY • Carbocisteine 50mg/mL 0.6 mL TID x 4 days
S
• Onset of intermittent fever (Tmax 38.8C) & cough became

3 productive with 3 episodes of post-tussive vomiting, non-
DAY bilous amounting 1 tbsp-50cc/episode
S
PAST MEDICAL HISTORY
(-) DM
(-) HPN
(+) COPD x 2 yrs

• Anoro 62.5/25mg 1 puff OD w/ good compliance
(-) BA; (-) thyroid dse (-) PTB tx
No food & drug allergies
No other prev surgeries

FAMILY HISTORY
(-) HPN
(-) DM,
(-) Cancer
(-) BA
(-) cardiac dse

PERSONAL & SOCIAL HISTORY
+exposure to dust from rice mills
(galingan)
Tobacco smoker for ~25 pack yrs
Non alcoholic beverage drinker
No illicit drug use

REVIEW
GE OF SYMPTOMS
CA
RDI
NE OV
RA ASC
• [-] weight loss UL
• L
[-] loss of appetite • [-] palpitation
• AR
[-] cyanosis/pallor
CUT • [-] fainting spell
ANE
RE
•OUS
[-] rash SPI
• [-] diaphoresis
RA
TO
HEE • RY
[-] hemoptysis
NT
• [-] epistaxis
• [-] salivation
• [-] sore throat
• [-] dizziness
END
OC
GIT
RIN
• [-] abdominal pain • E
[-] heat/cold intolerance
• [-] melena • [-] polydipsia
• [-] nausea/ vomiting • [-] sleep problems
• [-] jaundice
CNS
GU
T • [-] memory loss
• [-] mood changes
• [-] incontinence • [-] seizures
• [-] dysuria • [-] tremors
• [-] oliguria/polyuria • [-] vertigo
MUSC
[-] myalgia
ULO
[-] stiffness
[-] muscle/joint pain
PHYSICAL EXAMINATION
GENERAL SURVEY
awake, alert, conscious, coherent, oriented to time, place and
person, in mild respiratory distress, talks in sentences
VITAL SIGNS:
Blood pressure: 120/70 mmHg Respiratory rate: 26 cpm
Temperature: 36.2 °C
Pulse rate: 89 beats/min
Estimated body weight: 69 kg

Height: 198 cm
BMI: 17.6 kg/m2, (underweight)
SKIN
No jaundice and pallor.
No rash
Warm skin.
No tenderness.
Senile turgor
Eyes
Anicteric sclera
Pink conjunctivae
NECK
Trachea is midline. Neck supple. Neck veins are not distended. No
masses nor signs of tenderness.
CHEST AND LUNGS
Equal chest expansion,
no supraclavicular retractions, no use if accessory muscles,
No masses or tenderness.
(+) crackles bibasal
(+) min wheezing bilateral
CARDIOVASCULAR
Adynamic precordium.
Regular heart rate and rhythm.
No palpable thrills and heaves.
No murmurs.
ABDOMEN
Flat,, normoactive bowel sounds, soft, non-tender, no organomegaly.
GUT
Negative kidney punch sign bilaterally.
PERIPHERAL VASCULAR SYSTEM
Extremities are warm and without edema. No varicosities or stasis
changes. Pulses are 2+ and symmetric.
SALIENT FEATURES
HISTORY PHYSICAL
EXAMINATION
• 69 years old • Crackles, bibasal
• male • Wheezing bilateral
• Productive cough w/
inc sputum production
• COPD on anoro
• No fever
• No night sweats
In a Nutshell
 A case of an elderly male diagnosed case of
COPD who came in for dyspnea assoc with
cough and inc sputum production
WORKING IMPRESSION
COPD in acute exacerbation
 Acute exacerbation of COPD is a sudden
worsening of COPD symptoms (shortness of
breath, quantity and color of phlegm) that
typically lasts for several days.
COPD Risk Factors
 Risk Fx that put pt at inc risk of COPD are
cigarette smoking
 Occupational exposure
CLINICAL PRESENTATION
 The most common symptoms in COPD are cough, sputum production,
and exertional dyspnea which are all present in our patient
 Although the development of airflow obstruction is a gradual process,

many patients date the onset of their disease to an acute illness or
exacerbation.
physical examination of the lungs may include expiratory wheezing.
 Advanced disease may be accompanied by cachexia,

LABORATORY FINDINGS
 Pulmonary function testing shows airflow obstruction with a
reduction in FEV
1 and FEV1/FVC
 Arterial blood gases and oximetry may demonstrate resting or

exertional hypoxemia
 Radiographic studies may assist in the classification of the type

of COPD. Obvious bullae, paucity of parenchymal markings, or
hyperlucency on chest x-ray suggests the presence of emphysema
COPD GOLD criteria
 PFT postbronchodilator FEV1/FVC ratio of
<0.70 is commonly considered diagnostic for
COPD.
 GOLD 1 - mild: FEV1≥ 80% predicted

 GOLD 2 - moderate: 50% ≤FEV1 <80%
predicted
 GOLD 3 - severe: 30% ≤FEV1 <50% predicted
 GOLD 4 - very severe: FEV1 <30% predicted.
 Group A: low risk (0-1 exacerbation per year, not requiring
hospitalization) and fewer symptoms (mMRC 0-1 or CAT <10)
 Group B: low risk (0-1 exacerbation per year, not requiring

hospitalization) and more symptoms (mMRC≥ 2 or CAT≥ 10)
 Group C: high risk (≥2 exacerbations per year, or one or more

requiring hospitalization) and fewer symptoms (mMRC 0-1 or CAT
<10)
 Group D: high risk (≥2 exacerbations per year, or one or more

requiring hospitalization) and more symptoms (mMRC≥ 2 or CAT≥
10).
DIFFERENTIAL DIAGNOSIS
1. CAP –MR
2. PTB
3. Bronchial asthma
Ddx: CAP
 COPD patients are at increased risk to develop
CAP. Risk increased by older age due to
immunosuppresion, decreased cough and gag
reflexes Pt is an elderly 69yo and a dx case of
COPD. = increase likelihood of pneumonia.
CLINICAL MANIFESTATIONS
 Cough may be either nonproductive or productive of

mucoid, purulent, or blood-tinged sputum.
 However patient with CAP is frequently febrile with

tachycardia. But in our case, pt is afebrile, no tachycardia
P.E: increased respiratory rate and use of accessory muscles of

respiration are common.
 Crackles may be heard on auscultation.

Pulmonary Tuberculosis
 95% of cases were reported from developing
countries including the Philippines. Two-thirds of
cases typically occur in male patients.
Pt usually presents with cough (20-30% develop hemoptysis)

patient is usually dyspneic and cachectic. Some has crackles. But
in our case pt has No fever, No Night sweats which is typical of TB
• \
DEFINITIVE SUPPORTIVE
Spirometry
CT scan
CXR, Sputum GS/CS

ACTUAL PATIENT , sputum AFB,
Therapeutics
 Salbu + ipra q 4
 Hydrocort 100mg q 6
 PiperTazo 4.5g IV q 8
 Azith 500mg 1 tab OD
 NAC
 Budesonide neb q 12
End
 Thank you!

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IDENTIFYING DATA

SL DOB: Nov. 1, 2017

Cabantan St. Bo, Luz, Cebu City

Source of Info: Parents

• Persistence thus sought consult with a general physician

• Onset of intermittent fever (Tmax 38.8C) & cough became

(+) COPD x 2 yrs

No food & drug allergies

No other prev surgeries

(-) cardiac dse

Tobacco smoker for ~25 pack yrs

Non alcoholic beverage drinker

No illicit drug use

Estimated body weight: 69 kg

 Although the development of airflow obstruction is a gradual process,

physical examination of the lungs may include expiratory wheezing.

 Advanced disease may be accompanied by cachexia,

 Arterial blood gases and oximetry may demonstrate resting or

 Radiographic studies may assist in the classification of the type

 GOLD 1 - mild: FEV1≥ 80% predicted

 Group B: low risk (0-1 exacerbation per year, not requiring

 Group C: high risk (≥2 exacerbations per year, or one or more

 Group D: high risk (≥2 exacerbations per year, or one or more

 Cough may be either nonproductive or productive of

 However patient with CAP is frequently febrile with

P.E: increased respiratory rate and use of accessory muscles of

 Crackles may be heard on auscultation.

Pt usually presents with cough (20-30% develop hemoptysis)

CXR, Sputum GS/CS

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