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Case Presentation

Case Presentation. 성균관대학교 의과대학 2007313075 손의영. Chief Complain. 김 O 식 , M/83 Dyspnea Onset : 2 weeks ago. Present Illness. 2011.02 TB pleurisy 로 치료 받은 후에 간헐적으로 dyspnea 호소 2000.03.09 Pneumonia w/ respiratory failure 로 입원 후 치료받고 퇴원 2009. 우울증 진단 후 1 년간 medication 복용

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Case Presentation

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  1. Case Presentation 성균관대학교 의과대학 2007313075 손의영

  2. Chief Complain • 김O식, M/83 • Dyspnea • Onset : 2 weeks ago

  3. Present Illness • 2011.02 TB pleurisy로 치료 받은 후에 간헐적으로 dyspnea호소 • 2000.03.09 Pneumonia w/ respiratory failure로 입원 후 치료받고 퇴원 • 2009. 우울증 진단 후 1년간 medication 복용 • 2009.12. Cough, dyspnea로 충주의료원 입원 치료 Maniac episode 보여 bipolar disorder 진단 • 이후 1년에 약 1차례 씩 감기로 인한 dyspnea로 입원 치료 함

  4. Present Illness • 2011.04.05 cough, yellowish sputum 증가dyspnea aggravation  충주의료원 방문 Chest PA 상 Rt. Bronchopneumonia, COPD 의심되어 ICU 입원 • 2011.04.06 Foley catheter insertion • 2011.04.07 insomnia, hallucination 및 말이 많아지는 양상 보임 • 2011.04.09 스스로 line remove 하려고 하며 irritability 발생 ABGA 7.388 – 65.1 – 65.2 – 38.4 SpO2 91.7% CO2 retention aggravation 되어 보호자가 원하여 본원 내원

  5. Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( + / + / - / - / - ) • 약물력 • Drugs for Depression (During 1 year) • 수술력 • 없음 • FHx. • 특이사항 없음 • SHx. • Smoking: ex-smoker 30PA (30yr x 1 pack)

  6. Review of system • GW / EF ( + / + ) • Weight change ( - ) • Fever / chill ( - / - ) • Headache / dizziness ( - / - ) • Rhinorrhea / cough/ sputum ( - / + / + ) : yellowish • Dyspnea (+) : ATS grade III • chest pain / palpitation ( - / - ) • Anorexia / nausea / vomiting ( - / - / - ) • abdominal pain / discomfort ( - / - ) • Constipation / diarrhea ( - / - ) • Hematemesis / melena / hematochezia ( - / - / - ) • Urinary Sx ( - ) • Arthralgia ( - ) • Myalgia ( - )

  7. Physical Exam • V/S 140/83 mmHg - 108 - 24 - 36℃ • G/A Chronic ill-looking appearance • Mentality Alert & well orientation • HEENT not anemic conjunctivae, anictericsclerae Dehydrated tongue (-) PNS tenderness(-) PTH/PI (-/-) JVP (-) Neck VE (-) Cervical LNE (-/-) Thyroid enlagement (-) • Chest Symmetric chest expansion Iregular heart beat w/o murmur Clean breathing sound w/o wheezing

  8. Physical Exam • Abdomen Soft & flat Bowel sound – normoactive No tenderness/rebound tenderness No shifting dullness • Back No CVAT • Extremities Skin rash(-) Clubbing (-) Joint ROM limitation (-) Joint swelling & stiffness (-) Joint deformity (-)

  9. EKG

  10. Imaging

  11. Lab • WBC▲ 11.25 x10³/μL • Neut.▲ 92.2% (seg.) • Eo. 0.1% • RBC▼ 3.80 x10³/μL • Hb▼ 11.3 g/dL • Hct▼ 36.1% • PLT 262,000/μL • Protein▼ 4.2 g/㎗ • Albumin▼ 2.7 g/㎗ • Globulin▼ 1.5 g/㎗ • AST 35 U/l • ALT 37 U/l • ALP 77 U/l • BUN 21 mg/dL • Cr 0.92 mg/dL • BUN/Cr 23.0 • CRP▲ 4.06 mg/dL • Na 140 mmol/ℓ • K▼ 3.4 mmol/ℓ • Cl▼ 96 mmol/ℓ

  12. Problem List / Assessment • Problem List • #1. Dyspnea • #2. Depression • #3. Mania • #4. Aggravation of Cough and Sputum • #5. CO2 retention • #6. Leukocytosis • #7. increased CRP • Assessment • #1, 4, 5, 6, 7 : R/O Acute Exacerbation of COPD • #2, 3 : Bipolar disorder

  13. AE of COPD • Lung function test • PEF < 100 L/min or PEV1 < 1.00 L • ABGA • Respiratory failure : PaO2 < 60mmHg and/or SaO2 < 90% w/ or w/o PaCO2 > 50 mmHg in room air • Life threatening condition : PaO2 < 60 mmHg and PaCO2 > 70 mmHg and pH < 7.30

  14. AE of COPD – Etiology • Primary • Tracheobronchial infection • Air pollution • Secondary • Pneumonia yellowish sputum, CT GGO, • Pulmonary embolism but CT 특이소견 X • Pneumothoraxbut CXR 특이소견 X • Rib fracture / Chest trauma but Hx X • Inappropriate use of sedatives, narcotics, β-blocking agents • Right and/or Left heart failure or arrhythmias

  15. AE of COPD – Treatment • Controlled oxygen therapy • 목표치 : PaO2 > 60mmHg, SaO2 > 90% • 30분 후에 ABGA로 CO2 retention, acidosis 여부 파악 • Bronchodilator therapy • Short acting β2-agonist • Glucocorticoids • Antibiotics • Ventilatory support

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