SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Alcantara, Edna

SUBMITTED BY: de Leon, Jan Gil
De los Santos, Rosheil
Ditti, Fatimah Al-Zahra
Divinagracia, Joshua Luke
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 SYSTEMS
PHYSICAL EXAMINATION
General Survey: (+) fatigue and
weightloss
Skin: (-) rashes, sores, itching, and color
changes
HEENT: (+) headache and visual
haziness, doesn't wear eyeglasses; (-)
ear discharges, infection, earaches and
tinnitus; (+) pain on sinuses sometimes,
(-) nosebleeds, (-) toothaches, bleeding
gums and sorethroat
Neck: (-) neck pain and lumps
Respiratory: (+) cough with small
amount of white phlegm noted, (-)
hemoptysis (+) dyspnea
Cardiovascular: (-) Chest pain, HPN,
and palpitations

GIT: (-) pain on swallowing; bowel

movement 3x/day; (-) nausea and
vomiting
GUT: (-) polyuria; urinates 3x/day; (+)
pain on urination with hematuria
Genital: Started sexual activity after
marriage (1965); he now stopped sexual
activity with wife; (-) Genital discharges,
and pain
Peripherals: (-) Pain, claudication and
edema; (+) blue discoloration of lower
extremities after walking
Musculoskeletal: (-) Muscle and joint
pains, arthritis, inflammation and
stiffness
Neurologic: (-) Fainting,
seizures,paralysis and loss of sensation
Hematologic: (-) Anemia and easy
bruising/bleeding
Endocrine: (-) polyuria, excessive thirst
and heat or cold intolerance
Psychiatric: (-) Memory change,
nervousness and depression
LABORATORY & DIAGNOSTIC TESTS
LABORATORY TEST
RATIONALE
Complete Blood
CBC serves as a baseline data to determine the extent of the disease of the
Count
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.
Electrolytes
Patients with chronic obstructive pulmonary disease have a slower rate of
Na+
potassium exchange and an increase in residual sodium composed of intracellular
K+
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.
ECG
ECG should be done to exclude cardiac causes of dyspnea.
Arterial Blood Gas

COST
Php22
0

Php29
0

Php66
0

ABG 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
Spirometry
Spirometry measures the amount of airflow obstruction present. Normally, 75
80% of the FVC comes out in the first second and a FEV1/FVC ratio of less than
70% in someone with symptoms of COPD defines a person as having the disease.
Sputum G/S
In 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
are Streptococcus
pneumoniae and Haemophilus
influenzae.Moraxella catarrhalis is also a common organism, and Pseudomonas
aeruginosa can be seen in patients with severe obstruction.
Chest X-ray
A chest x-ray may offer early clues to other important diagnoses, such as Php27
pneumonia, CHF, pleural effusion, aortic dissection, and pneumothorax.
0
THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS
THERAPEUTIC OBJECTIVES
1. Dyspnea
1. To identify and treat underlying cause of the disease
2. Fever
2. To ensure adequate oxygenation

3. Fatigue
4. Weightloss
5. Cough
ADVICE AND INFORMATION
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 complications

3.
4.
5.
6.
1.
2.
3.
4.
5.

To
To
To
To

return the vital sign parameters to normal

provide adequate nutrition and hydration
restore/improve body strength
prevent complications
NON-PHARMACOLOGIC MANAGEMENT
Admit patient.
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.
Ensure patients hydration. Monitor Intake and Output.
Diet: NPO if patient is dyspneic
Position patient in high or semi-fowlers position to
facilitate easy breathing.