Case Presentation 2007313075 Chief Complain O M83 Dyspnea

Case Presentation 성균관대학교 의과대학 2007313075 손의영

Chief Complain � 김O식, 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 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

Present Illness � 2011. 04. 05 cough, yellowish sputum 증가 dyspnea 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 Sp. O 2 91. 7% CO 2 retention aggravation 되어 보호자가 원하여 본원 내원

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

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 ( - )

Physical Exam � V/S 140/83 mm. Hg - 108 - 24 - 36℃ � G/A Chronic ill-looking appearance � Mentality Alert & well orientation � HEENT not anemic conjunctivae, anicteric sclerae 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

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

EKG

Imaging

Lab �WBC▲ �Neut. ▲ �Eo. �RBC▼ �Hb▼ �Hct▼ �PLT �Protein▼ �Albumin▼ �Globulin▼ 11. 25 x 10³/μL 92. 2% (seg. ) 0. 1% 3. 80 x 10³/μL 11. 3 g/d. L 36. 1% 262, 000/μL 4. 2 g/㎗ 2. 7 g/㎗ 1. 5 g/㎗ �AST �ALP �BUN �Cr �BUN/Cr �CRP▲ �Na �K▼ �Cl▼ 35 U/l 37 U/l 77 U/l 21 mg/d. L 0. 92 mg/d. L 23. 0 4. 06 mg/d. L 140 mmol/ℓ 3. 4 mmol/ℓ 96 mmol/ℓ

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

AE of COPD �Lung function test � PEF < 100 L/min or PEV 1 < 1. 00 L �ABGA � Respiratory failure : Pa. O 2 < 60 mm. Hg and/or Sa. O 2 < 90% w/ or w/o Pa. CO 2 > 50 mm. Hg in room air � Life threatening condition : Pa. O 2 < 60 mm. Hg and Pa. CO 2 > 70 mm. Hg and p. H < 7. 30

AE of COPD – Etiology �Primary �Tracheobronchial infection �Air pollution �Secondary �Pneumonia yellowish sputum, CT GGO, �Pulmonary embolism but CT 특이소견 X �Pneumothorax but 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

AE of COPD – Treatment �Controlled oxygen therapy � 목표치 : Pa. O 2 > 60 mm. Hg, Sa. O 2 > 90% � 30분 후에 ABGA로 CO 2 retention, acidosis 여부 파악 �Bronchodilator therapy � Short acting β 2 -agonist �Glucocorticoids �Antibiotics �Ventilatory support