CASE PRESENTATION

by AMOT Dale Julian M. Adis

Intake July 2015
Demographic Details
Registration Number : LD00026220
Gender : Male
Age : 72yrs
Race : Dusun
Status : Local
Hospital : Hospital Lahad Datu
Department : Emergency and Trauma
Date Encounter : 3rd Oct 2017 @ 6:57pm
Primary Triage
Patient Came to casualty on 3rd Oct 2017 @ 6:57 pm

Brought to ETD by family members ( Son )

Chief Complaint :
Short of Breath since 2 days ago ( 01/10/17 )
History of Present Illness

Worsening SOB x 2/7 ( Even during rest )

Cough and Sputum ( white + greenish )

Fever

Lost of Appitite

Tachypneic
History ( Others )
Past Medical History
Known case of COPD ( since 2013 )

Allergies
No known allergic of food / drug

Social History
Married
Ex smoker
Started since year 1957
Quit smoking since year 2000
2 pax per day
Due to medical health condition
Self employment
General Examination
General Appearance
Alert
Conscious
Wheezing
Tachypneic
No palor
No sweating

GCS : 15/15
Eye opening = 4
Verbal Response = 5
Motor = 6
On Examination
Vital sign were taken at Red Zone
BP : 152/82 mmHg
PR : 101
Temp : 36.6c
RR : 28/min
SPO2 : 88% RA / 95% NSP
Pain Score : 1/10
Physical Examination
Examination of head and special sense
(mouth, throat, ears, nose, eyes, and neck)

1. Mouth
Normal Lips - Pink, no wound spotted.

2. Throat
Normal.
No sign of enlargement of tonsil.
Physical Examination
3. Ears
No discharge.
No swelling.

4. Nose
Normal.
No Septal Deviation.
No discharge.
No bleeding / infection.
Physical Examination
5. Eyes
No sign of Jaundice
Conjuctiva pink
Normal Eye
Pupil react to light

6. Neck
Symmetrical size
Visible pulsation of pulse neck
No tracheal deviation.
Chest Region ( Cardiovaskular System )
I. Inspection
No scar of post operation.
Barrel Chest.
occurs because the lungs are chronically
overinflated with air, so the rib cage stays
partially expanded all the time.
II. Palpation
Normal Apex beat.
III. Percussion
Normal cardiac dullness sound.
IV. Auscultation
Dual Rhythm No Murmur (DRNM).
Chest Region ( Respiratory System )
1. Trachea
No tracheal deviation

2. Inspection
Chest movement are abnormal (SOB)
Barrel Chest

3. Palpation
No abnormality
Non-Tenderness

4. Percussion
Normal Resonance

5. Auscultation
Bilateral Rhonci
Nervous System
Diagnosis

Impression : Chronic Obstructive Pulmonary Disease ( COPD )

Differential Diagnosis
Chronic Obstructive Airway Disease ( COAD )
Chronic Bronchitis
Pulmonary Tuberculosis ( PTB )
Acute Pulmonary Edema ( APO )
Emphysema
Bronchitis
Investigation
Blood Test
FBC
ABG
BUSE
DXT

Electrocardiogram (ECG)
presence of hyperexpanded emphysematous lungs within the chest.
long-term effects of hypoxic pulmonary vasoconstriction upon the right side of the heart, causing
pulmonary hypertension and subsequent right atrial and right ventricular hypertrophy

X-ray ( CXR )
to detect abnormality structur or any consolidation of lungs.

CT Scan
to detect abnormality of lungs

Serology test
Sputum C&S test to detect infection in lungs.
Management
1. Patient 72y, Male was Triage to Redzone.
2. Determined patient consciousness by performing GCS
3. Look for any obstruction in patient airways, proceed with oxygen if clear.
4. Patient was given high flow mask
to deliver high flow rates and high concentrations of oxygen
5. Patient was given face mask as requested
to breathe in the medicine.
Nebulizer turn medicine into a fine mist which is the ( aerosol. )
Given Neb V:A:N ( 1:2:3 ) STAT
Salbutamol = opens up the medium and large airways in the lungs.
( Sympathomimetic )
Ipratropium = treat the symptoms of COPD and ASTHMA ( anti cholinergics )
Normal Saline = sterile mixture of salt and water also called isotonic solution.
Given Neb V:N ( 1 : 3 ) STAT
6. Cardiac monitor is applied
7. Taken vital sign
Blood Pressure ( BP )
Pulse Rate ( PR )
Respiratory Rate ( RR )
Peripheral capillary oxygen saturation ( SPO2)
Temperature ( c )
Continue..
8. IV line size 18G inserted @ both hand.
to be given Normal Saline
to be given medicine
9. Taken blood sample for further investigation
ABG
FBC
BUSE
DXT
10. Given IV hydrocortisone 200mg
11. Radiological Investigation
Chest X-Ray
ECG
12. NPO2 2L/min applied.
13. Nursing care
14. Patient under observation
Other Management
Continuous Positive Airway Pressure ( CPAP )

It is the most popular treatment for obstructive sleep apnea (OSA).

It uses air pressure generated by a machine, delivered through a tube

into a mask that fits over the nose or mouth.

While originally intended to treat people with forms of sleep apnea, are
also considered helpful in improving sleep breathing for people with other
respiratory dysfunctions.

The patient places the mask on their face (either over their nose, or both
the nose and mouth) to receive pressurized air.

CPAP delivers a single preset air pressure to keep the airways open.
Continue..
Bilevel positive airway pressure (BiPAP) therapy

Often used in the treatment of chronic obstructive pulmonary disease (COPD). COPD is an
umbrella term for lung and respiratory diseases that make breathing difficult.

Modern BiPAP machines are tabletop devices fitted with tubing and a mask. You simply put
the mask over your nose and/or mouth to receive two levels of pressurized air. One
pressure level is delivered when you inhale, and a lower pressure is delivered when you
exhale.

Shortness of breath and wheezing are common symptoms of COPD, and these symptoms
can worsen as the condition progresses. BiPAP therapy targets these dysfunctional
breathing patterns.

By having a custom air pressure for when you inhale and a second custom air pressure
when you exhale, the machine is able to provide relief to your overworked lungs and chest
wall muscles.

The pressure in your airway encourages a steady flow of oxygen. This allows your lungs to
more efficiently transport oxygen to your body and remove excess carbon dioxide.
Side Effect of CPAP BiPaP
The most common side effects of BiPAP therapy include:

dry nose
nasal congestion
rhinitis
general discomfort
claustrophobia

BiPAP isnt an appropriate treatment for all people with respiratory problems. The most
concerning complications are related to worsening lung function or injury.

BiPAP can also be used to treat sleep apnea, especially when CPAP hasnt been helpful.

BiPAP machines provide two different levels of air pressure, which makes breathing out
easier than it is with a CPAP machine. For this reason, BiPAP is preferred for people with
COPD. It lessens the work it takes to breathe, which is important in people with COPD
who expend a lot of energy breathing.
Blood Test Results
Chemical path

BUSE
Na+ ( Natrium ) : 140 mmol/l (137-148)
K+ ( Potassium / Kalium ) : 4.6 mmol/l (3.5-5.1)
Urea : 1.9 mmol/l (1.7-8.3)
CL ( Chloride ) : 106 mmol/l (98-107)

Haematology

FBC
Hematocrit : 39.5% (40-54) Abnormal
MCV ( Corpuscular Volume ) : 78.7 fL (83-101) Abnormal
MCH ( Corpuscular Haemoglobin ) : 25.8pg (27-32) Abnormal
Lymphocyte Count : 19.8% (20-40) Abnormal
Continue..
Chemical path

ABG
PH : 7.457 mm HS (7.35-7.45) Abnormal
pCO2 : 38.3 mm HS (33-48)
pO2 : 176.6 mmol/L (80-100) Abnormal
HCO3ACT : 26.5 mmol/L (23-29)
BEECF : 2.6 mmol/L (-2.4-2.3) Abnormal
Oxygen Saturation : 99.3% (95-98) Abnormal
Total CO2 : 27.7 mmol/L (22-26) Abnormal
Result Chest X-Ray

COPD : Hyperexpansion
Case Discussion

Chronic Obstructive Pulmonary Disease (COPD)

Definition

Chronic obstructive pulmonary disease (COPD) is a

lung disease characterized by chronic obstruction of
lung airflow that interferes with normal breathing
and is not fully reversible.

The more familiar terms 'chronic bronchitis' and

'emphysema' are no longer used, but are now
included within the COPD diagnosis.
Sign and Symptoms

Increased Breathlessness

Frequent Coughing ( with and without sputum )

Wheezing

Tightness in the chest

To Determined the COPD Stages.
The two most common ways to determine the stages of COPD include
the:

Global Initiative for Chronic Obstructive Lung Disease ( GOLD ) Staging

System
The forced expiratory volume in one second ( FEV1 ) measurement
from a pulmonary function test is used to place COPD into stages.

Body mass, Obstruction of airflow, Dyspnea ( difficulty breathing ) and

Exercise capacity ( BODE ) Index
To better understand how COPD affects life and severity of the
symptoms.
Other ways to determined COPD Stages

Gas diffusion tests

6-minute walk tests

Body plethysmography

Spirometry
FEV1/FCV ratio = 0.70
Positive COPD < 0.70 > Negative COPD
The Stages of COPD

Mild COPD / Stage 1

Mild COPD with a Forced Expiratory Volume in One Second 1 ( FEV1 )
about 80% or more of normal

Moderate COPD / Stage 2

Moderate COPD with a FEV1 between 50 and 80% of normal.

Severe COPD / Stage 3

Severe emphysema with a FEV1 between 30 and 50% of normal.

Very Severe COPD / Stage 4

Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or
people with low blood oxygen levels and stage 3 FEV1
Risk Factors and Common
Causes
Smoking
COPD most often occurs in people 40 years of age and older with history of
smoking

Current or former smokers

Environmental Factors
had long-term contact with harmful pollutants in the working area.

Some of these harmful lung irritants include certain chemicals, dust or fumes.

Heavy or long-term contact with secondhand smoke or other lung irritants in the
home, such as organic cooking fuel may also cause COPD.

Genetic Factors
Even if an individual has never smoked or been exposed to pollutants for an
extended period of time, they can still develop COPD.
COPD's Origins and Pathophysiology
COPD is an unbrella term for several chronic lung diseases. The two main COPD
conditions are chronic bronchitis and emphysema. These affect different parts of
the lungs, but both lead to difficulty breathing.

When you inhale, air moves down your trachea through two tubes called bronchi.
The bronchi branch out into smaller tubes called bronchioles and at the ends of
the bronchioles are little air sacs called alveoli, and at the end of it was the
capillaries which are tiny blood vessels.

Oxygen moves from the lungs to the bloodstream through these capillaries.
Carbon dioxide moves from the blood into the capillaries and then into the lungs
and exhaled.

Emphysema is a disease of the alveoli. The fibers that make up the walls of the
alveoli become damaged. The damage makes them less elastic and unable to
work when you exhale.
Continue..
If the bronchioles become inflamed they produce mucus,
which is bronchitis. If the bronchitis persists, you can
develops chronic bronchitis. You can have temporary bouts of
acute bronchitis. But these episodes aren't considered COPD.

The main cause of COPD is smoking. Breathing in smoke

and chemicals can injure the airways and air sacs. This
leaves you vulnerable to COPD. Exposure to secondhand
smoke, chemicals and even cooking oils in poorly ventilated
buildings can also lead to lung diseases.
In normal subjects the
diaphragm is intersected by
the 5th to 7th anterior ribs in
the mid-clavicular line

It is often difficult to see the

ribs in patients with COPD as
they are osteopenic due to
long term steroid use - as in
this patient
The lungs may be so hyper-
expanded that the inferior
border of the heart becomes
visible, the heart appears to
float above the diaphragm
Bullous emphysema manifests
on a chest X-ray with areas of
low density (black) with
thinning of the pulmonary
vessels, predominantly
affecting the upper zones

The lower part of the lungs

may appear denser (whiter) in
normal subjects because of
overlying breast tissue, but in
this individual the pulmonary
vessels appear normal in this
area
Occasionally bullae are seen
as discretely outlined holes in
the lungs which resemble
bubbles
Bullae can get very large and
must not be mistaken for a
pneumothorax, inserting a
chest drain can have
catastrophic consequences in
this setting
The lungs are hyper-expanded
the diaphragm is flattened and
too low

There are large areas of black

due to bullae

A large area of consolidation in

the left lung is due to
pneumonia
Other Sign of COPD Progress
Besides coughing, patient may wheezing when they breathe.
The build-up of mucus and the narrowing of the bronchioles
and alveoli may also cause chest tightness. These aren't
normal symptoms of aging.

Less oxygen circulating throughtout your body can leave you

feeling fatigued. Lack of energy can be a symptom of many
conditions.

People with serious COPD, may result of weight loss as their

body requires more and more energy to breathe.
Preventation

Never start smoking

Stop smoking as soon as possible

Regular checkups and follow the advice of your

doctor.

Avoid being in crowded places.

Investigation
Lab Investigation
ABG : This test is used to check how well your lungs are able to move oxygen
into the blood and remove carbon dioxide from the blood

FBC : Check a person's general health or to screen for conditions such as

anaemia

BUSE : The creatinine blood test is used to assess kidney function

DXT : A blood glucose test measures the amount of glucose in your blood

Radiological Investigation
Chest Xray : When focused on the chest, it can help spot abnormalities or
diseases of the airways, blood vessels, bones, heart, and lungs.

Electrocardiogram (ECG) : Simple test that can be used to check your heart's
rhythm and electrical activity
Treatments
Neb V:A:N ( 1:2:3 ) STAT
Quick relieve medication
Salbutamol , Ipratropium , Normal Saline

Neb V:N ( 1:3 ) STAT

Quick relieve medication
Salbutamol , Normal Saline

IV Hydrocortisone 200mg STAT

to treat symptoms of low corticosteroid levels (lack of
certain substances that are usually produced by the body
and are needed for normal body functioning)
THANK YOU !!! :D