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CHIEF COMPLAINTS
Patient came through emergency with chief complaints of:
Sudden breathlessness
Cough, Sputum production, Restlessness since a week
PAST HISTORY
MEDICAL HISTORY
Past history of COPD present.
Patient has been admitted to AHRC, Muktsar with history of Respiratory distress and
nausea on June28, 2009; i.e. about six months back.
No past history of Tuberculosis, Bronchial asthma, Hypertension, Diabetes mellitus and
Jaundice, Typhoid fever.
SURGICAL HISTORY
No past surgical history.
PSYCHIATRIC HISTORY
No past history of any psychiatric illness.
HISTORY OF ALLERGY
Patient is not allergic to any medicine or diet.
PERSONAL HISTORY
Patient is vegetarian, non-smoker and non-alcoholic.
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FAMILY HISTORY
(a) Patient is unmarried.
(b) Patient lives in a joint family.
The socio-economic status of the family is moderate.
Father
Mother
PATIENT Brother
Family tree
GENERAL APPEARANCE
Nourishment- nourished
Body build- average, neither thin nor obese
MENTAL STATUS
Consciousness- Patient is conscious and well oriented to time place and person.
Look- relaxed. He is neither anxious nor worried.
POSTURE
Body curves- Absence of lordosis, kyphosis and scoliosis.
Movement- Movement of all extremities is well.
SKIN CONDITIONS
Color: Absence of Pallor, No jaundice and cyanosis
Texture: Normal
Temperature: Skin is warm to touch
Lesions: Absence of macules, papules and vesicles
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EYES
Patient’s eyes are normal.
No discharge from either eye, absence of infection, sty, redness and squint
EARS
External ear: no discharge
Tympanic membrane: not perforated
Hearing: Hearing acuity normal
NOSE
External nares: No crust or discharge
Nostrils: No septal deviation or inflammation
NECK
Lymph nodes, thyroid gland: Not enlarged
Range of motion: Can flex, extend and rotate
CHEST
Thorax: Shape and symmetry normal. On admission patient showed the use of accessory
muscles.
Heart: No enlargement in size, absence of any cardiac murmurs
ABDOMEN
Observation: absence of skin rashes, hernia, distension
Auscultation: Bowel sounds heard
Palpation: Normal, absence of abdominal distention and localized mass
Percussion: Absence of fluid or masses.
EXTREMITIES
Range of motion of all joints is well, absence of varicose veins and pedal edema, no
congenital abnormality
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SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
No history of any cardiovascular disease
No history of arrhythmias or murmurs.
Heart not enlarged.
GASTROINTESTINAL SYSTEM
Nausea was present since five days before admission. Now no such complaints.
There is absence of abdominal distention.
RESPIRATORY SYSTEM
Rate of respiration: 22/min.
Trachea is centrally placed. Shape and symmetry of thorax is normal.
Presence of breathlessness, restlessness
MUSCULOSKELETAL SYSTEM
No musculoskeletal deformity is observed. No history of fracture, kyphosis or scoliosis.
Range of motion of upper and lower extremities is well.
Absence of pedal edema.
Varicose veins absent.
INTEGUMENTARY SYSTEM
Skin turgor is good. No history of scabies or any other skin disease.
VITALS
DATE TEMPERATURE PULSE RESPIRATION BLOOD PRESSURE
(in Fahrenheit) beats per min (beats per min) (mmHg)
09-01-10 98.8 96 26 120/70
10-01-10 98.6 88 24 110/80
11-01-10 98.2 80 22 120/80
12-01-10 98.4 78 22 120/80
LABORATORY INVESTIGATIONS-HEMATOLOGY
Date Hb WBC Lymphocytes Monocytes Gramocytes
Normal Values 13-18 4-10 m/cu 15-40% 3-10% 30-70%
gm/dL mm
Jan.09, 2010 11.8 8.33 30.6 1.9 71.5
Jan.12, 2010 11.5 8.05 28.4 1.3 85.3
Jan.14, 2010 11.4 7.38 27.2 2.2 80.8
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BLOOD GASES AND SERUM ELECTROLYTES
DATE TESTS PATIENT’s VALUE NORMAL VALUE
Jan.09, 2010 Pco2 42.1 mmHg < 50 mmHg
So2 98.9% > 100 mm Hg
Jan.10, 2010 Cl 86.4 Mmol/lt 92-110 Mmol/lt
Jan.11, 2010……
ECG REPORT
Shows Tachycardia
Narrow QRS Complex
Variable PR interval
CHEST X-RAY
Shows consolidation in both of the lungs.
TREATMENT
Inf.
Levofloxacin Levofloxacin OD IV 100ml Antibiotic
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COMPARATIVE STUDY
IN BOOK IN PATIENT
DEFINITION
According to Global initiative for Chronic Obstructive Lung Disease, Airflow
“COPD is a disease state characterized by airflow limitation that is not limitation
fully reversible.” present.
INCIDENCE
(a) Race Absent
COPD is more common in whites than blacks.
(b) Gender Present
COPD affects men more frequently than women. (Men)
(c) Age group Present
COPD affects middle aged and older adults. It affects 1 out of 14 (70years)
people over the age of 45years.
(d) Place of residence Absent
It is more frequent in clients living in urban environments.
(e) Socioeconomic status
COPD is found more frequent among the low socioeconomic group Absent
CAUSES/RISK FACTORS
(a) Exposure to tobacco smoke
It accounts for 80-90% of COPD cases. Absent
(b) Passive smoking
Occupational exposure to dust and chemicals. Absent
(c) Air pollution Absent
(d) Heredity Absent
Genetic abnormality including a deficiency of alpha1 antitrypsin, an
enzyme inhibitor that normally counteracts the destruction of lung
tissue by certain other enzymes.
(e) Respiratory infections/microbes Present
(f) Low socioeconomic status Absent
COPD is found more frequent among the low socioeconomic group
(g) Age Present
COPD affects middle aged and older adults
(h) Place of residence Absent
It is more frequent in clients living in urban environments.
PATHOPHYSIOLOGY
In COPD, the airflow limitation is both progressive and associated with
an abnormal inflammatory response of the lungs to noxious particles
and gases. COPD includes two disease conditions:
a) Chronic Bronchitis
b) Emphysema
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CHRONIC BRONCHITIS
Definition
Bronchitis is the inflammation of the bronchioles.
Chronic Bronchitis is a disease of the airways and is characterized by
the presence of cough and sputum production for at least three months
in each of the two consecutive years.
EMPHYSEMA
Definition
It is a disorder in which the alveolar walls are destroyed which leads to
permanent over distention of air spaces.
TYPES
(a) Pan lobular /Panacinar emphysema
The bronchioles, alveolar ducts and alveoli are destroyed and air spaces
within the lobule are enlarged.
(b) Centrilobular/ centroacinar emphysema
The pathologic changes are seen in the center of the secondary lobule
while the peripheral positions of the acinus are preserved.
CLINICAL MANIFESTATIONS
COPD is characterized by three primary symptoms: Present
a) Cough
b) Sputum
c) Dyspnea
EARLY STAGE
Daily morning cough Present
Mild shortness of breath Present
Occasional coughing Present
Severe cough from respiratory infection Present
Wheezing: usually only after a respiratory infection
FURTHER STAGE
Present
Chronic cough
Present
Sputum: Clear, colorless Present
Shortness of breath on exertion
LATER STAGES
INSPECTION Absent
Nicotine stains Present
Cough Present
Sputum production: Mucopurulent, sometimes blood may also Present
be present Present
Dyspnea: both on exertion and rest Absent
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Cyanosis Absent
Clubbing of digits Present
Fatigue and weakness Absent
Pursed lip breathing Absent
Barrel chest Absent
Use of accessory muscles of respiration
Distended neck veins Absent
PALPATION Absent
Pulsus Paradoxus
Pitting peripheral edema
PERCUSSION
Hyper resonance on percussion Present
ADVENTITIOUS BREATH SOUNDS
Adventitious breath sounds: Rhonchi, Wheezing Present
OTHERS
Weight loss
Bullae
Chest X- ray: flat diaphragm
Heart: Enlarged, ECG shows right heart strain pattern
Liver: Enlarged and pulsating
DIAGNOSTIC EVALUATIONS
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In COPD,
The total lung capacity (TLC) and residual volume (RV) are
increased.
The forced expiratory volume (FEV1) and forced vital capacity
(FVC) are decreased due to narrowed airways and resistance to
airflow. Chronic Lung Disease is a disease defined as a
FEV1/FVC ratio of less than 70%.
Normal values
Total lung capacity (TLC) = TV + IRV + ERV + RV
= 500ml + 3000ml + 1100ml + 1200ml
= 5800ml
Residual volume (RV) = 1200ml
Normal values
PARAMETER ARTERIAL VENOUS SAMPLE
SAMPLE
pH 7.35-7.45 7.35-7.41
PaCO2 35-45mmHg 35-40mmHg
Oxygen saturation 93-98% 65-75%
HCO3- 22-26mEq/L 24-28mEq/L
Done
4. PULSE OXIMETRY
It is a non-invasive method of continuously monitoring the oxygen
saturation of hemoglobin.
A probe or sensor is attached to the fingertip, forehead, earlobe or
bridge of the nose. The sensor detects changes in oxygen saturation
levels by monitoring high signals generated by the oximeter and
reflected by blood pulsing through the tissue at the probe. Normal
SpO2 values are 98% to 100%. Values less than 85% indicate that the
tissues are not receiving enough oxygen.
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Pulse oximetry may be continuously monitored to assess the need for
supplemental oxygen.
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9. SPUTUM STUDIES Not done
Sputum is obtained to
Identify pathogenic organisms and to determine whether
malignant cells are present.
Assess for hypersensitivity states (in which there is an increase
in eosinophills).
STAGES OF COPD
STAGE CHARACTERISTICS
0 Normal spirometry
Chronic symptoms of cough,
sputum production
I FEV1/FVC< 70%
(Mild FEV > 80% predicted
COPD) May or may not have chronic symptoms of
cough, sputum production
II FEV1/FVC< 70%
(Moderat FEV between 30% and 80% predicted
e COPD) May or may not have chronic symptoms of
cough, sputum production
III FEV1/FVC < 70%
(Severe FEV1 < 30% predicted or FEV< 50% predicted plus
COPD) respiratory failure or clinical signs of right heart failure.
MANAGEMENT
I. MEDICAL MANAGEMENT
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aminophylline
theophylline
1. BULLECTOMY
A bullectomy is a surgical option for selected patients with bullous
emphysema. bullae are enlarged airspaces that do not contribute to
ventilation but occupy space in the thorax, these areas may be
surgically incised.
many times these bullae compress areas of the lung that do not have
adequate gas exchange. Bullectomy may help reduce dyspnea and
improve lung function it can be done thoracoscopically or via a limited
thoracotomy incision.
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This is a treatment option for end-stage COPD (stageIII) patients. it
involves the removal of portion of the diseased lung parenchyma. this s
allows the functional tissue to expand, resulting in improved elastic
recoil of the lung and improved chest wall and diaphragmatic
mechanics. this type of surgery does not cure the disease but it may
decrease dyspnea, improve lung function and improve the patients
overall quality of life.
3. LUNG TRANSPLANTATION
It is a viable alternative for definitive surgical treatment of end stage
emphysema. It has been shown to improve quality of life and functional
capacity. however, organs are in short supply and many patients die
while waiting for a transplant.
COMPLICATIONS
PROGNOSIS
- COPD is a major cause of death and illness throughout the world. in
fact, it is the Fourth leading cause of death worldwide. COPD is a
disease that slowly worsens over time, especially if the person
continues to smoke. a person with COPD has lung infections, which
can be fatal. if the lungs are severely damaged, the heart may be
affected as well.
- A person with COPD eventually dies when the lungs and heart are
unable to function and get oxygen to the body’s organs and tissues or
when a complication, such as severe infection occurs.
NURSING MANAGEMENT
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To make the patient aware about the disease process.
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