Mpprc 2 (b7)

MPPRC

1. APPROACH TO A PATIENT WITH DYSPNEA MPPR CONFERENCE Group 7 2-B Gison, R. Go, C. Go, H. Go, R. Godisan, P. Gomez, F. Gonzales, D. Gonzales, K. Granda, A. Guevarra, K. Gumafelix, R. Guzman, A. ‹#›

2. MDI 2: Part 1 ‹#›

3. GODISAN, Paulo Gabriel M. MEDICAL HISTORY 69 year old male, retired school bus driver Chief complaint: Dyspnea 11 years PTA 7 years PTA 5 years PTA 1 year PTA 1 week PTA Few hours PTA ADMISSION Diagnosed with COPD since 2006 COPD exacerbation Pneumonia which presented as “hingal” COPD in acute exacerbation with pneumonia Productive cough and colds with dyspnea Experienced “hingal” while on the elevator

4. PAST MEDICAL HISTORY GODISAN, Paulo Gabriel M. Birth and Developmental History No congenital or birth defects Childhood Illness/Hospitalizations None Adult illnesses BPH (2012) Hypertension (2015) ASHD, CAD s/p NSTEMI NIF Class IIB (2017)

5. PAST MEDICAL HISTORY GODISAN, Paulo Gabriel M. Surgeries Stab wound repair (1976; JRMMC) Cyst Removal (1980s;Lung Center of the Philippines) Cataract Left (2010;Bridgestone Clinic) Cataract Right (2012;USTH) Glaucoma Left (2014/2013;USTH)

6. PAST MEDICAL HISTORY GODISAN, Paulo Gabriel M. Injuries/accidents See surgeries Transfusions/reactions PRBC (1976) due to stab wound Allergies None Vaccinations Pneumococcal Vaccine (2017)

7. PAST MEDICAL HISTORY GODISAN, Paulo Gabriel M. MEDICATION HISTORY Atorvastatin 80 mg OD Ivabradine 5 mg OD Trimatezidine 35 mg 2x daily Clopidogrel 35 mg OD Losartan 50 mg OD Aspirin 80 mg OD Diltiazem 30 mg OD Theophylline 200mg/tab Indacaterol (Ultibro) one puff OD Tiotropium (Spiriva) OD N-Acetylcysteine (Fluimucil) 600mg as needed Lactulose syrup as needed Bisacodyl 5mg/tab OD if needed Alfusozin 10mg OD Phenylpropanolamine HCL/ Chlorphenamine maleate/ Paracetamol (Symdex-D Forte) Ipratropium+Salbutamol neb Brimodine eye drops Brinzolamide eye drops

8. PERSONAL/SOCIAL HISTORY No current risk factors Well-balanced diet Sleep pattern not altered, normal Pulmonary Rehabilitation at USTH every Tuesday and Friday from 8:30 to 11:30 am GODISAN, Paulo Gabriel M.

9. PERSONAL/SOCIAL HISTORY Previous smoker with 25 pack years Has history of smoking dried banana leaves 5-6 bottles/month of alcohol; stopped 2012 Exposure to Construction Site pollution and Car smoke Denies recreational drug use GODISAN, Paulo Gabriel M.

10. PERSONAL/SOCIAL HISTORY GODISAN, Paulo Gabriel M. Widower At present lives, in a 4 storey home with 2 children and 4 grandchildren. Good emotional and financial support from family and patient’s service award money

11. PERSONAL/SOCIAL HISTORY GODISAN, Paulo Gabriel M. 1 sexual partner No recent deaths, divorce or financial hardships in the family Mason at construction site, seaman, direct seller, loan investigator, jeepney driver for 3 years, taxi driver, delivery man

12. FAMILY HISTORY Father - (+) Asthma, (+) HPN, deceased Brother - (+) Pneumonia 4 th Sibling - (+) Arthritis GODISAN, Paulo Gabriel M.

13. REVIEW OF SYSTEMS GENERAL: (+)weight loss , (-)fever, (-)malaise, (-) change in appetite, (-) sleeping patterns SKIN, HAIR, NAILS: (+)mole change, (-) itchiness, (-)color change,(-) hyperpigmentation, (-)hypopigmentation (-)depigmentation, (-)rash, (-)vasomotor change (-)texture change, (-)photosensitivity, (-) change in hair, (-)abnormal hair growth, (-) excessive sweating EYE: (+)blurring of vision (Farsighted), (+)itchiness, (-)photophobia, (-)redness, (-)pain, (-)lacrimation, (-)periorbital swelling, (-)doubling of vision, (-)trauma EAR: (+)tinnitus , (-)deafness, (-)discharge, (-)ear pain NOSE: (-)epistaxis, (-)discharge, (-)obstruction, (-)abnormal sense of smell, (-)sinus pain, (-)postnasal drip MOUTH: (-)bleeding gum, (-)soreness of tongue, (-)fissure, (-)tongue abnormality, (-)dental pain, (-)disturbance of taste THROAT (-)soreness, (-)tonsillar pain, (-)hoarseness/change in voice, (-)mass, (-)sensation of lump in throat NECK: (-)mass, (-)stiffness (-)limitation of motion PULMONARY: see HPI GODISAN, Paulo Gabriel M.

14. REVIEW OF SYSTEMS CARDIAC: (+)easy fatigability, (-)chest pain, (-)paroxysmal nocturnal dyspnea, (-)orthopnea, (-)palpitations, (-)syncope, (-)leg edema GIT: (+)occassional hematochezia due to hemorrhoids, (+)constipation, (-)nausea/vomiting, (-)retching, (-)hematemesis, (-)melena, (-)hematochezia, (-)dysphagia, (-)belching, (-)indigestion, (-)food intolerance, (-)heartburn, (-)flatulence, (-)abdominal pain, (-)diarrhea, (-)abdominal mass, (-)jaundice GUT: (-)dysuria, (-)anuria, (-)hematuria, (-)nocturia, (-)penile discharge, (-)genital lesion, (-)scrotal pain, (-)swelling/lesions, (-)urinary incontinence MUSCULOSKELETAL: (+)joint stiffness,(+)pain, (-)swelling,(-)muscle pain, (-)cramps, (-)weakness, (-)trauma, (-)wasting, (-)abnormal posture NEURO: (-)headache, (-)seizure, (-)loss of consciousness, (-)No motor dysfunction, (-)abnormalities of coordination, (-)speech disturbance, (-)loss of memory/ability to concentrate, (-)abnormality of sensation, (-)head trauma, (-)tremors VASCULAR: (-)phlebitis, (-)variceal pain/swelling, (-)claudication, (-)leg discoloration, (-)extremity temperature change HEMATOLOGIC: (-)bruising,(-)pallor GODISAN, Paulo Gabriel M.

15. MDI 2: End of Part 1 ‹#›

16. MDI 2: Part 2 ‹#›

17. February 09, 2018 12:24PM PE on admission VITAL SIGNS BP: 130/90 mmHg HR: 73 beats/min RR: 21 breaths/min T: 36.6˚C O 2 sat: 98% February 10, 2018 11:00am Current PE VITAL SIGNS BP: 140/90mmHg HR: 75 beats/min RR: 21 breaths/min T: 36. 5 ˚C O 2 sat: 98% GO, Cybele Liana D.

18. February 09, 2018 12:24PM PE on admission GENERAL SURVEY General appearance : Conscious, coherent, in distress, on 2-3LPM O2 via nasal cannula Specific signs of respiratory distress, cyanosis, body habitus February 10, 2018 11:00am Current PE GENERAL SURVEY General appearance : slight discomfort, (-) preference for upright seated position, (-)respiratory distress , (+)nasal cannula, (+) cough with sputum production, (-)edema Skin color/lesions : no cyanosis, no flushing , no jaudice, no pallor, no obvious lesions Facies : normal facies Level of consciousness : Conscious, coherent, GCS 15 Posture : slightly hunched, (-) tripod Body habitus: hyposthenic Odors : no characteristic odor Psychomotor: normal speech and movement Thought process : sensible and realistic Cognitive function s: oriented to time, place, intact memories Mood/Affect: uncooperative GO, Cybele Liana D.

19. February 09, 2018 12:24PM PE on admission HEENT EYE: Anicteric sclerae, pink palpebral conjunctiva, EOM intact on both eyes, isocoric pupils 2-3 ERTL EARS: No deformities, no otorrhea, no tragal tenderness NOSE: (+) minimal clear secretions , no mass, no deformities, nasal septum midline MOUTH: moist lips and buccal mucosa, no oral ulcer, non-hyperemic posterior pharyngeal wall, no lesions, no masses, tonsils not enlarged NECK: thyroid not enlarged, no palpable cervical lymph nodes, trachea midline February 10, 2018 11:00am Current PE HEENT EYE: Anicteric sclerae, pink palpebral conjunctiva, EOM intact on both eyes, in tact pupillary light reflex EARS: No deformities, no otorrhea, no tragal tenderness, pearly grey tympanic membrane, intact cone of light NOSE: no mass, no deformities, nasal septum midline MOUTH: moist lips and buccal mucosa, no oral ulcer, non-hyperemic posterior pharyngeal wall, no lesions, no masses, tonsils not enlarged NECK: thyroid not enlarged, no palpable cervical lymph nodes, trachea midline GO, Cybele Liana D.

20. February 09, 2018 12:24PM PE on admission SKIN No active dermatoses, moist, warm EXTREMITIES Pulses full and equal GIT Globular, normoactive bowel sounds, tympanitic on all quadrants, nontender GUT (-) CVA tenderness February 10, 2018 11:00am Current PE SKIN No active dermatoses, moist, warm, no discoloration, (+)scar on left shoulder EXTREMITIES (-) clubbing , (-)nicotine staining of nails, pulses full and symmetrical, (-)change in temperature of extremities GIT Globular, normoactive bowel sounds, tympanitic on all quadrants , nontender, (-)vein prominence, (-)lesions GUT (-) CVA tenderness GO, Cybele Liana D.

21. GO, Cybele Liana D. February 09, 2018 12:24PM PE on admission NEUROLOGICAL EXAM conscious, coherent, awake, alert, able to respond to questions, follows commands, GCS15 (E4V5M6) Cranial Nerves CNI – not assessed CN II – 2-3mm ERTL, isocoric CN III, IV, VI – EOM full and intact CN V – can clench teeth, no sensory deficit CN VII – can raise eyebrows, close eyes CN VIII – gross hearing intact both ears CN IX, X – velar elevation CN XI – uvula midline CN XII – tongue midline Motor : 5/5 MMT on upper and lower extremities Cerebellum : (-) tremors, (-) dyskinesia, (-) dysdiadochokinesia Sensory : No sensory deficit on all extremities Reflexes : ++ DTR on all extremities, (-)Babinski Meningeal: (-) Nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski sign February 10, 2018 11:00am Current PE NEUROLOGICAL EXAM conscious, coherent, awake, alert, able to respond to questions, follows commands, GCS15 (E4V5M6) Cranial Nerves CNI – not assessed CN II – isocoric, direct and consensual reflex intact CN III, IV, VI – EOM full and intact CN V – can clench teeth, no sensory deficit CN VII – can raise eyebrows, close eyes CN VIII – gross hearing intact both ears CN IX, X – velar elevation CN XI – uvula midline CN XII – tongue midline Motor : 5/5 MMT on upper and lower extremities Cerebellum : (-) tremors, (-) dyskinesia, (-) dysdiadochokinesia Sensory : No sensory deficit on all extremities Reflexes : ++ DTR on all extremities, (-)Babinski Meningeal: (-) Nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski sign

22. GO, Cybele Liana D. February 09, 2018 12:24PM PE on admission CARDIOVASCULAR Adynamic precordium no lifts, heaves or thrills rhythm and rate regular apex beat 5 th LICS MCL Loud S1 followed by soft S2 at the apex, soft S1 followed by loud S2 at the base, no murmurs, (-)S3 February 10, 2018 11:00am Current PE CARDIOVASCULAR Adynamic precordium No neck vein distention no lifts, heaves or thrills rhythm and rate regular apex beat 5 th LICS MCL, not diffused, not sustained Loud S1 followed by soft S2 at the apex, soft S1 followed by loud S2 at the base, no murmurs , (-)S3 Peripheral pulses full and equal JVP: 3.0cm at 30˚ CAP: brisk upstroke gradual downstroke

23. GO, Cybele Liana D. February 09, 2018 12:24PM PE on admission RESPIRATORY symmetrical chest expansion normal tactile and vocal fremiti (+) dull on percussion, right (+)rhonchi and crackles, bilateral apex (+)wheeze, right base February 10, 2018 11:00am Current PE RESPIRATORY (+)barrel chest , symmetrical chest wall, (-) chest wall lesions or deformities (-)Hoover’s sign, (-) abdominal paradox, (-) intercostal retractions, (-) SCM prominence trachea midline symmetrical chest expansion decreased tactile fremiti, right (+) dullness on percussion, lower right (+) fine crackles, late inspiratory, bibasal (+) wheeze, bibasal

24. Lung Auscultogram GO, Cybele Liana D. (+)rhonchi and crackles, bilateral apex

25. (+)wheeze, right base Lung Auscultogram GO, Cybele Liana D.

26. x (+) dull on percussion, right Lung Auscultogram GO, Cybele Liana D.

27. Lung Auscultogram

28. MDI 2: End of Part 2 ‹#›

29. MDI 2: Part 3 ‹#›

30. CHIEF COMPLAINT: DYSPNEA Subjective (symptom) Breathing discomfort Vary in quality and intensity Experienced with or without disease Multifactorial Clinically significant when felt at unacceptably low exertion GUEVARRA, Kathryn Jed P. Sources: Murray & Nadel’s Textbook of Respiratory Medicine 6th ed Vol 1 p 485 Spruit, M. A., Singh, S. J., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., ... & Pitta, F. (2013). An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. American journal of respiratory and critical care medicine, 188(8), e13-e64. ‹#›

31. GUEVARRA, Kathryn Jed P. Source: Harrison’s Principles of Internal Medicine 19th ed Vol 1 p 243 ‹#›

32. GUEVARRA, Kathryn Jed P. Source: Davidson’s Principles and Practice of Medicine 22nd ed p 674 ‹#›

33. MECHANISM OF DYSPNEA GUEVARRA, Kathryn Jed P. Source: ‹#›

34. ORGAN SYSTEMS GUEVARRA, Kathryn Jed P. Source: Harrison’s Principles of Internal Medicine 19th ed Vol 1 p 244 ‹#›

35. ORGAN SYSTEMS GUEVARRA, Kathryn Jed P. Source: Harrison’s Principles of Internal Medicine 19th ed Vol 1 p 244 RESPIRATORY CARDIOVASCULAR Airway Left Heart Chest Wall Pulmonary Vasculature Lung Parenchyma Pericardium ‹#›

36. Salient Features 69 y/o male, Retired school bus driver ‹#› GUZMAN. A. CARDIOVASCULAR SYSTEM SUBJECTIVE PERTINENT (+) OBJECTIVE PERTINENT (+) Dyspnea Easy Fatigabilty Productive cough COPD since 2006 Pneumonia (2013) Hypertension (2015) ASHD, CAD s/p NSTEMI NIF Class IIB (2017) 25 pack years (stopped 2006) 5-6 bottles per month since grade 6 (stopped 2012) Family History : Hypertension BP: 130/90 mmHg RR: 21 breaths/min Conscious, coherent, in distress, on 2-3LPM O2 via nasal cannula (+)barrel chest (+) dull on percussion, right decreased tactile fremiti, right (+) dullness on percussion, lower right (+) fine crackles, late inspiratory, bibasal (+) wheeze, bibasal SUBJECTIVE PERTINENT (-) OBJECTIVE PERTINENT (-) (-)chest pain, (-)paroxysmal nocturnal dyspnea, (-)orthopnea, (-)palpitations, (-)syncope, (-)leg edema HR: 73 beats/min ; T: 36.6˚C; O 2 sat: 98% symmetrical chest wall, (-) chest wall lesions or deformities (-)Hoover’s sign, (-) abdominal paradox, (-) intercostal retractions, (-) SCM prominence; trachea midline Adynamic precordium no lifts, heaves or thrills rhythm and rate regular apex beat 5 th LICS MCL; Loud S1 followed by soft S2 at the apex, soft S1 followed by loud S2 at the base, no murmurs, (-)S3

37. Salient Features 69 y/o male, Retired school bus driver ‹#› GUZMAN. A. RESPIRATORY SYSTEM SUBJECTIVE PERTINENT (+) OBJECTIVE PERTINENT (+) Dyspnea Easy Fatigabilty Productive cough COPD since 2006 Pneumon ia (2013k Hypertension (2015) ASHD, CAD s/p NSTEMI NIF Class IIB (2017) 25 pack years (stopped 2006) 5-6 bottles per month since grade 6 (stopped 2012) Family History : Hypertension BP: 130/90 mmHg RR: 21 breaths/min Conscious, coherent, in distress, on 2-3LPM O2 via nasal cannula (+)barrel chest (+) dull on percussion, right decreased tactile fremiti, right (+) dullness on percussion, lower right (+) fine crackles, late inspiratory, bibasal (+) wheeze, bibasal SUBJECTIVE PERTINENT (-) OBJECTIVE PERTINENT (-) (-)chest pain, (-)paroxysmal nocturnal dyspnea,. (-)orthopnea, (-)palpitations, (-)syncope, (-)leg edema HR: 73 beats/min; T: 36.6˚C; O 2 sat: 98% symmetrical chest wall, (-) chest wall lesions or deformities (-)Hoover’s sign, (-) abdominal paradox, (-) intercostal retractions, (-) SCM prominence; trachea midline Adynamic precordium no lifts, heaves or thrills rhythm and rate regular apex beat 5 th LICS MCL; Loud S1 followed by soft S2 at the apex, soft S1 followed by loud S2 at the base, no murmurs, (-)S3

38. ORGAN SYSTEMS GUZMAN. A. Source: Harrison’s Principles of Internal Medicine 19th ed Vol 1 p 244 ‹#›

39. Respiratory RESTRICTIVE ‹#› GONZALES, K Source: Harrison’s Principles of Internal Medicine 19th ed Vol 1 p 244

40. Respiratory OBSTRUCTIVE: COPD, PNEUMONIA ‹#› GONZALES, K

41. ‹#› RESTRICTIVE OBSTRUCTIVE EXAMPLES IDIOPATHIC PULMONARY FIBROSIS PLEURAL EFFUSION ASTHMA COPD CHARACTERISTICS BIBASAL CRACKLES, DULLNESS ON PERCUSSION, DECREASED TACTILE FREMITI, RHONCHI, TACHYPNEA BARREL CHEST, DECREASED TACTILE FREMITI, BIBASAL CRACKLES, WHEEZES, HYPERRESONANCE, TACHYPNEA, RHONCHI, CYANOSIS, DECREASED BREATH SOUNDS LUNG FUNCTION DECREASED COMPLIANCE: REDUCTION IN LUNG VOLUME INCREASED COMPLIANCE: REDUCTION OF AIRFLOW GONZALES, K

42. ‹#› COPD ASTHMA AGE OF ONSET AGE AFTER 40 YEARS BEFORE 20 YEARS RISK FACTOR CIGARETTE SMOKING ALLERGIES PATHOPHYSIOLOGY AIRWAY LIMITATION AIRWAY RESPONSIVENESS SYMPTOMS EXERTIONAL DYSPNEA WITH OR WITHOUT WHEEZING COUGH WITH MUCUS DO NOT VARY SIGNIFICANTLY OVER DAYS POOR RESPONSE TO TREATMENT DYSPNEA WHEEZING NON-PRODUCTIVE COUGH SYMPTOMS AT NIGHT/EARLY MORNING VARIATION OVER MINUTES, HOURS, DAYS PHYSIOLOGIC MANIFESTATION INCREASED AIRWAY RESISTANCE INCREASED LUNG COMPLIANCE HYPERINFLATION INCREASED AIRWAY RESISTANCE INCREASED LUNG COMPLIANCE HYPERINFLATION OBSTRUCTION IRREVERSIBLE REVERSIBLE GONZALES, K

43. Disease: COPD ‹#› GONZALES, K

44. ‹#› GONZALES, K

45. COPD ‹#› GONZALES, K

46. Barrel chest ‹#› GONZALES, K

47. Cough ‹#› GUMAFELIX, R.

48. Cough Reflex ‹#› INSPIRATORY PHASE - Glottis opens on reflex - Inhalation of gas/air - Positive pressures generated COMPRESSIVE PHASE - Glottis closure - High intrathoracic and intra-abdominal pressure EXPULSIVE PHASE - Glottis opens - Rapid expiratory flow

49. ‹#› ACUTE SUBACUTE CHRONIC <3 weeks 3-8 weeks >8 weeks DRY PRODUCTIVE Virus infection Allergies Laryngitis Tracheobronchitis Tuberculosis Bacterial pneumonia Bronchitis Postnasal drip Harrison’s Principles of Internal Medicine (19th Ed) Classifications of Cough

50. Pneumonia ‹#› GUMAFELIX, R. Exposure to chronic stimuli (cigarette smoking and occupational exposure) Oxidant-Antioxidant imbalance Activation of Inflammatory cells

51. ‹#›

52. Dullness on Percussion, lower right GO , Herizza Anjeline D .

53. Wheeze Continuous and Musical Quality Expiratory usually Indicates narrowing of airways either due to bronchospasm or secretions in small airways Low pitch or High pitch High pitch polyphonic or monophonic GO , Herizza Anjeline D . ‹#›

54. Rhonchus Low Pitch or Sonorous wheeze Caused by airway narrowing due to secretions Usually heard both during inspiratory and expiratory GO , Herizza Anjeline D . ‹#›

55. Crackles Interrupted and Non-musical quality Inspiratory usually Peripheral airway collapse on expiratory due to either interstitial fibrosis or secretions/fluid Can be early, mid, late inspiratory or biphasic Fine or Course quality GO , Herizza Anjeline D . ‹#›

56. Acute Exacerbation of COPD GO , Herizza Anjeline D .

57. MDI 2: End of Part 3 ‹#›

58. MDI 2: Part 4 ‹#›

59. PATHOLOGY

60. Gross Pathology Image from https://kingsnc2d.wikispaces.com/Fischer+Biology GRANDA, Alyssa Anne E.

61. GRANDA, Alyssa Anne E. COPD Emphysema Chronic bronchitis Image from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc.

62. EMPHYSEMA Image from https://commons.wikimedia.org/wiki/File: Emphysema, _centrilobular_(4563050405).jpg Image from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc. GRANDA, Alyssa Anne E.

63. EMPHYSEMA NORMAL EMPHYSEMA Image from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc. Image from Young, B., Lowe, J.S., Stevens, A. & Hath, J.W. (2011.) Wheater’s Functional Histology (9th Ed.). Philadelphia: Elsevier Inc. GRANDA, Alyssa Anne E.

64. EMPHYSEMA NORMAL EMPHYSEMA GRANDA, Alyssa Anne E. Image from Young, B., Lowe, J.S., Stevens, A. & Hath, J.W. (2011.) Wheater’s Functional Histology (9th Ed.). Philadelphia: Elsevier Inc. Image from https://library.med.utah.edu/WebPath/LUNGHTML/LUNG059.html

65. Image from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc. GRANDA, Alyssa Anne E.

66. GRANDA, Alyssa Anne E.

67. Chronic bronchitis NORMAL CHRONIC BRONCHITIS Images from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc. GRANDA, Alyssa Anne E.

68. Chronic bronchitis NORMAL CHRONIC BRONCHITIS GRANDA, Alyssa Anne E. Image from https://library.med.utah.edu/WebPath/LUNGHTML/LUNG055.html Image from Kumar, V., Abbas, A., Aster, J. (2015). Robbins and Cotran Pathologic Bases of Disease (9th Ed.). Philadelphia: Elsevier Inc.

69. COPD: Chronic bronchitis & Emphysema GRANDA, Alyssa Anne E.

70. END OF PART 4

71. RADIOLOGY and SPIROMETRY ‹#›

72. ‹#› GOMEZ , Frederick Ferdinand S PA VIEW 7-12-17 AP VIEW 7-25-17

73. ‹#› GOMEZ , Frederick Ferdinand S AP VIEW 8-30-17 AP VIEW 7-25-17

74. ‹#› GOMEZ , Frederick Ferdinand S AP VIEW 8-30-17 AP VIEW 9-2-17

75. ‹#› GOMEZ , Frederick Ferdinand S AP VIEW 10-3-17 AP VIEW 9-2-17

76. Diagnostic Tests Blood Test Pulse Oximetry Sputum smear Arterial Blood Gas (ABG) Electrocardiogram (ECG) ‹#› GOMEZ, Frederick Ferdinand S

77. SPIROMETRY Spirometry is a physiological test that measures how an individual inhales or exhales volumes of air as a function of time. The primary signal measured in spirometry may be volume or flow. ‹#› GOMEZ, Frederick Ferdinand S Miller, M., Hankinson, V., Brusasco, V., … Wanger J. (2005). Standardisation of spirometry. European Respiratory Journal . 6 ( 2) 319-338. DOI: 10.1183/09031936.05.00034805 Figure. (A) Flow-volume loop of a normal subject. (B) Severe airflow limitation in a subject with COPD

78. ABCD ASSESSMENT TOOL ‹#›

79. MDI 2: End of Part 5 ‹#›

80. MDI 2: Part 6 ‹#›

81. Therapeutic Goals Prevent disease progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality http://www.who.int/respiratory/copd/management/en/ ‹#› GO, Ralph Anton C.

82. Drugs for Relief of COPD (Bronchodilators) Beta 2 Agonists Short-Acting (SABA): Salbutamol, Terbutaline Long-Acting (LABA): Formoterol, Salmeterol Ultra-Long Acting: Indacaterol , Vilanterol Anticholinergic Drugs MoA: competitive antagonists to ACh at M3 receptors on smooth muscles → blocking bronchospasm, dec mucus secretion Atropine, Ipratropium bromide, Tiotropium Methylxanthines MoA: Inhibits phosphodiesterase (PDE) → inc cAMP → smooth muscle relaxation Theophylline, Doxophylli ne Combination better and more sustained bronchodilation Salbutamol + Ipratropium bromide Katzung, Trevor (2015). Basic and Clinical Pharmacology 13th Ed. ‹#› GO, Ralph Anton C.

83. ESSC: Bronchodilators Drug Efficacy Safety Suitability Cost Total Salbutamol (SABA) +++ +++ +++ +++ 12 Tiotropium (Anticholinergic drugs) +++ +++ +++ +++ 12 Theophylline (Methylxanthine) ++++ ++ ++ ++++ 12 Salbutamol + Ipratropium bromide ++++ +++ ++++ +++ 14 The Philippine Drug Price Reference Index (DOH), 2017 5th Ed. ‹#› GO, Ralph Anton C.

84. Drugs for Reduction of Exacerbation ( Anti-Inflammatory) Corticosteroids MoA: inhibition of production of proinflammatory cytokines and chemokine → decrease trafficking of lymphocytes, eosinophils, & other leukocytes → dec bronchial hyperactivity Prednisone, Methylprednisole Methylxanthines MoA: Inhibits phosphodiesterase (PDE) → inc cAMP → smooth muscle relaxation Theophylline, Doxophylline Leukotrienes Inhibition of 5-lipoxygenase → dec formation of the cys-LT5 & LTB4 Montelukast Katzung, Trevor (2015). Basic and Clinical Pharmacology 13th Ed. ‹#› GO, Ralph Anton C.

85. ESSC: Anti-Inflammatory Drugs Drug Efficacy Safety Suitability Cost Total Methylprednisolone (Corticosteroid) ++++ +++ ++++ +++ 14 Theophylline (Methylxanthine) +++ ++ ++ ++++ 11 Montelukast (Leukotrienes) +++ ++++ +++ ++++ 14 The Philippine Drug Price Reference Index (DOH), 2017 5th Ed. ‹#› GO, Ralph Anton C.

86. Drug for Reduction of Mucus Hypersecretion Secretagogues MoA: stimulate the secretion of ions and fluid from the epithelial & serous cells resulting in thinning of airway secretions Ambroxol Mucolytics dissolves thick mucus and is usually used to help relieve respiratory difficulties N-Acetylcysteine, S-carboxymethylcysteine Expectorants Acts as local irritants → stimulating cough by vagal reflex → thinning of sputum Guiafenesin, ipecac Katzung, Trevor (2015). Basic and Clinical Pharmacology 13th Ed. ‹#› GO, Ralph Anton C.

87. ESSC: Drug Efficacy Safety Suitability Cost Total Ambroxol ( Secretagogues ) ++++ +++ ++++ +++ 14 N-Acetylcysteine ( Mucolytics ) +++ ++ ++ ++++ 12 Guiafenesin ( Expectorants ) +++ ++++ +++ +++ 14 The Philippine Drug Price Reference Index (DOH), 2017 5th Ed. ‹#› GO, Ralph Anton C.

88. Antibiotic Therapy for CAP-MR IV Non-antipseudomonal Beta-lactam (Cephalosporins or Carbapenem) MoA: binds with Penicillin-Binding Protein (PBP) → blocks transpeptidase cross-linking of peptidoglycan in cell wall → causes inhibition of cell wall synthesis 4th Gen Cephalosporin: Cefepime Carbapenem: Imipenem, meropenem, ertapenem + extended Macrolide MoA: (Protein Synthesis Inhibitor) bind to the 50s subunit → block peptide chain elongation Erythromycin, Clarithromycin , Azithromycin Philippine Clinicla Practice Guidelines on the Diagnosis, Management, and Prevention of CAP (2010) Katzung, Trevor (2015). Basic and Clinical Pharmacology 13th Ed. ‹#› GO, Ralph Anton C.

89. ESSC: Beta-Lactams Drug Efficacy Safety Suitability Cost Total Cefepime +++ ++ +++ ++ 10 Meropenem (Carbapenem) +++ ++ +++ ++ 10 The Philippine Drug Price Reference Index (DOH), 2017 5th Ed. ‹#› GO, Ralph Anton C.

90. ESSC: Macrolides Drug Efficacy Safety Suitability Cost Total Erythromycin ++++ ++ ++ ++++ 12 Clarithromycin ++++ ++++ +++ +++ 14 Azithromycin ++++ ++++ ++ ++ 11 The Philippine Drug Price Reference Index (DOH), 2017 5th Ed. ‹#› GO, Ralph Anton C.

91. ‹#› GO, Ralph Anton C.

92. Non-Pharmacologic Treatment General Medical Care Influenza Vaccine (annually) Harrison’s Principle of Internal Medicine 19th edition p. 1706-1707 GO, Ralph Anton C. Oxygen supplementation ‹#›

93. Non-Pharmacologic Treatment Smoking cessation Harrison’s Principle of Internal Medicine 19th edition p. 1706-1707 Less exposure to environmental pollutants ‹#› GO, Ralph Anton C.

94. Non-Pharmacologic Treatment Physical activity/Exercise Harrison’s Principle of Internal Medicine 19th edition p. 1706-1707 Pulmonary rehabilitation ‹#› GO, Ralph Anton C.

95. Non-Pharmacologic Treatment Lung volume reduction surgery Harrison’s Principle of Internal Medicine 19th edition p. 1706-1707 Lung transplant ‹#› GO, Ralph Anton C.