Cagayan State University- Carig Campus

College of Medicine and Surgery

CASE #3

MEDICINE DE CURIE: MAY 03, 2018

PRESENTED BY:

MED III-C

CLUELESS GROUP

CONAG, RICH MARK

DACAYO, JODEX
SALVADOR, MAR VENUS
TAGUINOD, CARMINA

PRECEPTOR:

DR. SHERYL CELINO-BAJET

MEDICAL WARD DECURIE A.Y.’17-‘18

PATIENT’S GENERAL DATA:

Name: PA
Age: 79 y/o
Birthdate: March 17, 1939
Sex: Male
Civil Status: Single
Religion: Church of Christ
Occupation: Unemployed
Address: Quezon, Isabela
Educational Attainment: Elementary Grad
Number of Admission/s: 1
Present Hospital of Admission: CVMC
Date of Admission: April 05, 2018, 10am
Referral: Quezon Community Hospital
Date of Interview and Assessment:
Informant: Patient and Niece
Reliability: 90%

CHIEF COMPLAINT:

DOB verbalized by the patient as “Narigatan nak aganges”.

HISTORY OF PRESENT ILLNESS:

10 Days PTA, upon waking up in the morning, the patient had difficulty of breathing, gasping for
air and felt some pleuritic pain on movement. He decided to have bed rest that day since no work awaits
him aside from household chores.
3 Days PTA, midmorning while feeding their pigs, patient felt dyspneic and after 30 minutes, this
progressed to intolerable difficulty of breathing which prompted his sister to call for immediate help to
bring him to nearest hospital. He was confined for 3 days with X-ray and ECG done.
April 05, 2018 patient was transferred to CVMC ER and was admitted upon proper referral. BP
was noted was 130/100mmHg, maintained at O2 via nasal cannula due to DOB. He underwent ECG,
XRAY however immediately wheeled to Medical Ward for further management.

MEDICAL WARD DECURIE A.Y.’17-‘18

PAST MEDICAL HISTORY:

Patient PA said he never had the chance n or had money to seek any medical consult despite
feeling some symptoms of “aging “as he fondly refer to his arthritis, occasional fever, cough and colds.
In the course of his lifetime he would usually resort to OTC drugs (like paracetamol tablet or alaxan) to
treat fever, cough, colds, and body pains. He said that for the past 3 years he occasionally experienced
nape pain but ignores it since it would usually subside on rest

PERSONAL AND SOCIAL HISTORY:

PA is single, currently unemployed and had been in shifting stay with his 4 siblings for the past 5
years since their parents died. He is the eldest in the family and for the last two years two of his siblings
also died, one from lung disease and the other from acid ingestion (suicide). PA also would usually spend
his day doing household chores and attending to domestic animals (pigs, ducks and dogs). The house
where he stays is semi concrete built, with two rooms, uncrowded and well ventilated. He would also
resort to firewood when cooking food but just outside the house.
He finished elementary with good reading and writing comprehension. He speaks native Ilokano
and Tagalog fluently. His preferred meal (3x a day) typically consists of meat/ pork, less vegetables and
high in fats.

Patient is a chronic smoker since 14 y/o and consumes 1 pack per day .He stopped just recently
because of health condition. He consumes alcohol occasionally with no illicit drug use noted

FAMILY HISTORY:

Patient GA is eldest in a brood of 4. No noted hereditary, familial or childhood diseases from

both sides like Asthma, no allergies to any food or drugs. His mother died d/t Hypertension and Father
d/t to liver failure secondary to chronic alcoholism.
Paternal Maternal
Ca + +
HPN - +
DM - -
1`Heart Dse. - -

REVIEW OF SYSTEMS:
SKIN: No presence of sores nor changes in mole size and color, no pruritus, no rashes, no cyanosis
HEAD, EYES, EARS, NOSE, THROAT (HEENT):
Head: no headache, no lumps
Eyes: no blurring of vision, no discharges/secretions
Ears: no discharges, no otalgia.

MEDICAL WARD DECURIE A.Y.’17-‘18

 Nose: with secretions (clear in color), no other symptoms.
Throat: no odynophagia, no swelling noted
NECK: no neck rigidity
CHEST: no lumps, no asymmetry noted
RESPIRATORY: (-) difficulty in breathing at time of interview
CARDIOVASCULAR: No chest pain, no palpitations
GASTROINTESTINAL: no nausea or vomiting, no diarrhea, no reports of changes in bowel movement
URINARY: No Frequency, dysuria nor any flank pain.
GENITAL: No swelling, no secretions noted
PERIPHERAL VASCULAR: No history of phlebitis or pain; no varicosities noted
MUSCULOSKELETAL: no spastic paralysis, no calf pain
PSYCHIATRIC: no history of psychiatric disorders, no significant behavioral changes noted NEUROLOGIC:
no fainting, motor or sensory loss, no focal weakness noted
HEMATOLOGIC: no history of anemia
ENDOCRINE: no known thyroid disorders, no polyuria, no polydipsia, no polyphagia nor metabolic
disorders

PHYSICAL EXAMINATION:

GENERAL SURVEY: The patient is conscious and cooperative during the course of interview and
assessment. He is sitting straight without support but weak to walk independently With IVF of 1L
D5Water on KVO inserted on the left hand

VITAL SIGNS:
Temperature: 36.5⁰C- afebrile Blood Pressure: 110/70 mmHg - normal
Pulse Rate: 82 bpm- normal O2 Sat: 98% - normal
Respiratory Rate: 22 cpm- normal Weight: 48 kg

SKIN: No cyanosis noted. No clubbing of nails, cyanosis.

HEAD, EYES, EARS, NOSE, THROAT (HEENT):
Head: Hair of average texture, Normocephalic
Eyes: pupils equally round, reactive to light and accommodation, sclera dirty white, anicteric
Ears: no infections, no swelling, no discharges noted
Nose: mucosa pink, septum midline
Throat: No significant finding
NECK: Neck supple, no tracheal deviation noted, no lumps, no resistance to head turning
THORAX and LUNGS: Thorax symmetric with bilateral thoracotomy w/ drainage. Fine crackles noted on

MEDICAL WARD DECURIE A.Y.’17-‘18

upper lung field.
LYMPH NODES: No swollen lymph nodes noted.
CARDIOVASCULAR: Apical pulse heard at 5th ICS midaxillary line. No murmurs noted.
ABDOMEN: No tenderness or masses. Bowel sounds active.
EXTREMITIES: Warm without edema. No varicosities noted.
MUSCULOSKELETAL: Good range of motion in hands and wrists. No joint deformities.
NEUROLOGIC:
Mental Status: Conscious, coherent and cooperative.
Motor: Good muscle bulk and tone, resists against force
CRANIAL NERVES I-XII: intact

SALIENT FEATURES:

 Sudden intolerable difficulty of breathing  Chronic smoker

 Pleuritic pain on movement  Age (79 years old)

DIFFENTIAL DIAGNOSIS

BRONCHIECTASIS
Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung.
Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness
of breath, coughing up blood, and chest pain.
RULE IN RULE OUT
 Difficulty of breathing  (-) persistent chronic cough
 Crackles on lung auscultation  (-) sputum production
 Presentation of obstructive pulmonary disease
EMPHYSEMA
Emphysema is a long-term, progressive disease of the lungs that primarily causes shortness of breath
due to over-inflation of the alveoli (air sacs in the lung). In people with emphysema, the lung tissue
involved in exchange of gases (oxygen and carbon dioxide) is impaired or destroyed.
RULE IN RULE OUT
 Difficulty of breathing  (-) cough
 Age  (-) sputum production
 Chronic smoker  (-) exertional dyspnea

IMPRESSION:

Pneumothorax Secondary to COPD

MEDICAL WARD DECURIE A.Y.’17-‘18

EPIDEMIOLOGY:

WORLWIDE

The Global Burden of Disease Study reports a prevalence of 251 million cases of COPD globally in
2016.

Globally, it is estimated that 3.17 million deaths were caused by the disease in 2015 (that is, 5% of all
deaths globally in that year). (Source: WHO)

MEDICAL WARD DECURIE A.Y.’17-‘18

Spontaneous pneumothorax (SP) has annual incidences of 18–28 and 1.2–6 cases per 100,000 men and
women, respectively. The annual incidences of Primary SP among men and women are 7.4–18 (age-
adjusted incidence) and 1.2–6 cases per 100,000 population, respectively; the annual incidences of
Secondary SP are similar, approximately 6.3 and 2 cases per 100,000 men and women, respectively.

NEPAL
Age-standardized death rates of COPD in Nepal during 1990–2016, by sex

In 2016, an estimated 16,302 people died from COPD in Nepal. Between 1990 and 2016, the mortality
rate due to COPD was decreasing for both genders, but the decline was much higher among males when
compared with females. Thus, by 2016, the age-standardized death rate due to COPD for the females
was 119.7 per 100,000 people while for the males it was 102.6 per 100,000 people.

Age-standardized incidence and prevalence rate of COPD during 1990–2016 in Nepal, by sex

The age-standardized prevalence rate of COPD has remained almost stagnant (4,899.1 per 100,000
population in 1990 vs 4,810.3 per 100,000 in 2016) over 26 years, with continued higher prevalence
among Nepalese males than females.

MEDICAL WARD DECURIE A.Y.’17-‘18

Age-wise COPD prevalence, mortality, and DALYs in Nepal in 2016.

With the increase in the age (group) of the population, the overall prevalence rate, death rate and
DALYs rate were found to increase steadily.

Abbreviation: DALYs, disability-adjusted life years

INDIA

MEDICAL WARD DECURIE A.Y.’17-‘18

 PHILIPPINES

In the Philippines, it ranks as the

7th leading cause of death with
a prevalence rate of 13.8% in
Manila.(2,3) Despite the high
incidence of COPD in the
Philippines, only 2% of the cases
are diagnosed by doctors in
contrast to the overall
prevalence. (4)The cause of this
under-diagnosis and under-
treatment is probably due to
lack of public health awareness
of COPD in our country.

DISCUSSION:

A pneumothorax is a collapsed lung. A pneumothorax occurs when air leaks into the space
between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse. In
most cases, only a portion of the lung collapses.

A pneumothorax can be caused by a blunt or penetrating chest injury, certain medical

procedures, or damage from underlying lung disease. Or it may occur for no obvious reason. Symptoms
usually include sudden chest pain and shortness of breath. On some occasions, a collapsed lung can be a
life-threatening event.

Treatment for a pneumothorax usually involves inserting a flexible tube or needle between the
ribs to remove the excess air. However, a small pneumothorax may heal on its own.

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that
causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum)
production and wheezing. It's caused by long-term exposure to irritating gases or particulate matter,
most often from cigarette smoke. People with COPD are at increased risk of developing heart disease,
lung cancer and a variety of other conditions.

Symptoms

COPD symptoms often don't appear until significant lung damage has occurred, and they usually
worsen over time, particularly if smoking exposure continues. For chronic bronchitis, the main symptom
is a daily cough and mucus (sputum) production at least three months a year for two consecutive years.
Other signs and symptoms of COPD may include:

 Shortness of breath, especially during physical activities

 Wheezing

MEDICAL WARD DECURIE A.Y.’17-‘18

  Chest tightness
 Having to clear your throat first thing in the morning, due to excess mucus in your lungs
 A chronic cough that may produce mucus (sputum) that may be clear, white, yellow or greenish
 Blueness of the lips or fingernail beds (cyanosis)
 Frequent respiratory infections
 Lack of energy
 Unintended weight loss (in later stages)
 Swelling in ankles, feet or legs

Causes of airway obstruction

Causes of airway obstruction include:

 Emphysema. This lung disease causes destruction of the fragile walls and elastic fibers of the
alveoli. Small airways collapse when you exhale, impairing airflow out of your lungs.
 Chronic bronchitis. In this condition, your bronchial tubes become inflamed and narrowed and
your lungs produce more mucus, which can further block the narrowed tubes. You develop a
chronic cough trying to clear your airways.

Cigarette smoke and other irritants

In the vast majority of cases, the lung damage that leads to COPD is caused by long-term
cigarette smoking. But there are likely other factors at play in the development of COPD, such as a
genetic susceptibility to the disease, because only about 20 to 30 percent of smokers may
develop COPD.
Other irritants can cause COPD, including cigar smoke, secondhand smoke, pipe smoke, air pollution and
workplace exposure to dust, smoke or fumes.

Alpha-1-antitrypsin deficiency

In about 1 percent of people with COPD, the disease results from a genetic disorder that causes
low levels of a protein called alpha-1-antitrypsin. Alpha-1-antitrypsin (AAt) is made in the liver and
secreted into the bloodstream to help protect the lungs. Alpha-1-antitrypsin deficiency can affect the
liver as well as the lungs. Damage to the lung can occur in infants and children, not only adults with long
smoking histories.

For adults with COPD related to AAt deficiency, treatment options include those used for people
with more-common types of COPD. In addition, some people can be treated by replacing the
missing AAt protein, which may prevent further damage to the lungs.
Risk factors

Risk factors for COPD include:

 Exposure to tobacco smoke. The most significant risk factor for COPD is long-term cigarette
smoking. The more years you smoke and the more packs you smoke, the greater your risk. Pipe
smokers, cigar smokers and marijuana smokers also may be at risk, as well as people exposed to
large amounts of secondhand smoke.
 People with asthma who smoke. The combination of asthma, a chronic inflammatory airway
disease, and smoking increases the risk of COPD even more.

MEDICAL WARD DECURIE A.Y.’17-‘18

  Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes, vapors
and dusts in the workplace can irritate and inflame your lungs.
 Exposure to fumes from burning fuel. In the developing world, people exposed to fumes from
burning fuel for cooking and heating in poorly ventilated homes are at higher risk of
developing COPD.
 Age. COPD develops slowly over years, so most people are at least 40 years old when symptoms
begin.
 Genetics. The uncommon genetic disorder alpha-1-antitrypsin deficiency is the cause of some
cases of COPD. Other genetic factors likely make certain smokers more susceptible to the disease.

Prevention:

Unlike some diseases, COPD has a clear cause and a clear path of prevention. The majority of
cases are directly related to cigarette smoking, and the best way to preventCOPD is to never smoke —
or to stop smoking now.

If you're a longtime smoker, these simple statements may not seem so simple, especially if
you've tried quitting — once, twice or many times before. But keep trying to quit. It's critical to find a
tobacco cessation program that can help you quit for good. It's your best chance for preventing damage
to your lungs.

Occupational exposure to chemical fumes and dust is another risk factor for COPD. If you work
with this type of lung irritant, talk to your supervisor about the best ways to protect yourself, such as
using respiratory protective equipment.

REFERENCES:

Harrisons Internal Medicine 19th ed

www.emed.com, pubmed
Bates Physical Assessment
Snell’s and High Yield Neuroanatomy referrences

MEDICAL WARD DECURIE A.Y.’17-‘18