GENERAL DATA:

This is the case of Nacis, Dionisio T., 79 years old, Male, Married, Filipino, Iglesia ni
cristo, residing at ALMEDIA, Balaoan, La union, who was admitted at Lorma Medical Center on
September 25, 2016 at 11:53 AM due to difficulty of breathing, cough.
Subjective:
c/c:
Aguyuyok ak ken marigatan nak aganges as verbalized by the patient
HPI:
About weeks PTA, patient started to produce cough, with associated intermittent
undocumented febrile episode/ There were no associated colds, chest discomfort, palpations and
dizziness. No consult was done. No medication were taken.
few hours PTA, there was persistence of productive cough with now noted chest
heaviness and difficulty of breathing. Consult was done at Bacnotan District Hospital where
patient was given initial treatment. Patient was transferred in this institution and was
subsequently admitted.
PMHx:
(+) HTN: Amlodipine
(+) COPD
(-) DM
(-) History of PTB
(-) Allergies
(-) Operations
PSHx:
(+) pack year smoker (stopped 1962)
(+) History of alcohol drinking (stopped 1962)
Objective:
Vital Signs:
BP: 150/100 mmHg
HR: 105 bpm
RR: 44 cpm
T: 36 C
- Moderate to severe distress

OI:

Barrel Chest

Cyanotic

Frequent weak cough

Productive cough with prevalent, gray yellow spectrum

Using accessory muscles of inspiration, prolonged expiration

Digital clubbing

Skin:
Cold clammy, no pallor, no jaundice
Head:
anicteric sclarae, pink palpebral conjunctiva. (+) supraclavicular retraction, (+)
suprasternal retractions, no TPC, no CLAD, no nasal discharge
Thorax:
symmetrical chest expansion, (+) subcostal retraction, (+) diffuse rates on both lungs,
adynamic precordium. Tachycardic, regular rhythm
Abdomen:
flabby, non-distended, normoactive bowel sounds, tymapanic, soft, non-tender
Lymph Nodes:
no cervical lymphadenopathies
Genitalia:
NA
Rectal:
NA
Auscultation:
- Diminished heart and Breath sounds
-

Bilateral wheezes, bronchi, and crackles could be heard over all lung fields

Chest X-ray Findings:

- Hyperinflation
-

Depressed diaphragms

Increased bronchial vascular markings

Cervical Blood Gas values on a 2L/min via O2 consumed a

PH- 7.24
PCO2 7.24
HCO3- 55
PaO2- 47
Spo2- 77%
Assessment:
- Bronchospasm (wheezing)
-

Excessive airway secretions (COPD history) rhonchi, crackles, prevalent, gray,

yellow spectrum

Poor ability to mobilize secretion (weak cough effort)

Air trapping (hyper resonant percussion notes, hyperinflation on x-ray film, barrel
chest)

Partially compensated respiratory Acidosis with mild hypoxemia

Plan:
-

Notify physician status regarding acute respiratory failure

Recommend mechanical ventilation protocol

Start Aerosolized Medication Protocol (combination shout acting beta2 agonist plus
long acting anticholinergic e.g. (salbutamol/ipvatropium)

Start bronchopulmonary hygiene therapy protocol (chest physical therapy gid, suction
prn.)

Position patient at High back rest

Instruct patient to do pursed lip breathing

Objective:
PA:
Anterior view: B sh. are elevated
Posterior view: sh. retracted
Lateral view:
supraclavicular retraction,
barrel chest,
increase kyphosis,
head protraction
Assessment:
PT Impression:
Pt. has difficulty performing ADLs such as prolonged walking and carrying loads
and stair negotiation d/t illness and decrease endurance. Pt. also presented c problems
in balance as well as postural (head forward, increase kyphosis, elevated shoulder and
barrel chest) and rapid shallow breathing pattern.
Problem List
STG
LTG
1. SOB 2 to illness
Pt. will have mod. ease of
Pt. will have min, difficulty
breathing d/t fluid
of breathing d/t fluid
secretions in 1 wk.
secretion in 3 wks.
2. Abnormal posture
Pt. will be able to do
Pt. will be able to do
2 to illness
proper posture to prevent
proper posture of 90%
further complication within within a mon
2 wks.
3. Pt. has diff.
Pt. will have increase
Pt. will have min. Difficulty
Responding ADLs
endurance measured by
in performing ADLs within
(walking, stair
200f more distance in 6
6 wks.
negotiation) 2 dec. mins ergobike. Mod.
enducrance
difficulty in performing
ADLs within 3 wks.
4. Pt. has problems c Pt. will have no problem in Pt. will have no problem in
balance
d/t within 5 mins standing
balance during standing
prolonged rest
within 2 wks.
and ambulation within 1

mon.
Plan:
PT Mx:
1. HMP on upper back for 15 to ease fluid secreation
2. Proper breathing training/ education (pursed lip breathing and diaphragmatic
breathing)
3. Postural drainage/ dranaige secretions
Percussion: 30s x 2 sets
Vibration: 200/min x 5 min
4. Frenkels Exercise for balance training
5. Ergobike for endurance training 6 or as tolerated
6. Patient education on proper positioning and body mechanics

Lorma Colleges
Carlata, San Fernando City, La Union
College of Physical and Respiratory Therapy

In Partial Fulfillment in Clinical Education 2

Chronic Obstructive Pulmonary Disease

Submitted to:
Ms. Teresa Rose Combalicer, PTRP
Submitted by:
Cruz, Wenzy Razzie
Dominguez, Louise Joy
Estacio, Patricia Ashley
Fernandez, Bryan

BACHELOR OF PHYSICAL THERAPY IV

What Is Chronic Obstructive Pulmonary Disease (COPD)?
In chronic obstructive pulmonary disease, the airways in your lung lose their normal shape and
elasticity, and can become inflamed. The result is that the airways are less efficient at moving air
in and out of your lungs. Primary risk factors for developing COPD include:

Smoking
Inhaling toxic substances
Indoor and outdoor pollutants
Genetic/environment interactions
Respiratory insult to the developing lungs during prenatal or early childhood stages of life

Current research indicates that COPD is no longer considered a smokers or older persons
disease.

The most common types of COPD are:

Chronic bronchitisa chronic inflammation of the medium-size airways, or "bronchi" in

the lungs, causing a persistent cough that produces sputum (phlegm) and mucus for at
least 3 months per year, in 2 consecutive years.
Emphysemaa condition in which small air sacs in the lungs called "alveoli" are
damaged. The body has difficulty getting all of the oxygen it needs, resulting in shortness
of breath ("dyspnea") and a chronic cough.
In addition to causing breathing difficulty, COPD results in cough, sputum production, and other
symptoms. The disease can affect the whole body and lead to:
Weakness in the arms and legs

Balance problems and increased risk of falls

Nutritional problems (weight loss or gain)
People with COPD are likely to have other health problems that can occur at the same time or
be related to COPD, such as:

Reduced blood supply to the heart (ischemic heart disease)

High blood pressure(hypertension)
Depression
Lung cancer
Osteoporosis
Diabetes
Congestive heart failure
Coronary artery disease
Atrial fibrillation
Asthma

Over time, COPD leads to a progressive decline in physical function because of increased
shortness of breath (dyspnea) and loss of muscle strength. There are 4 stages of COPDmild,
moderate, severe, and very severebased on measurements of the amount or flow of air as
you inhale and exhale. People with COPD may need to take medications, or may require
supplemental oxygen.
Epidemiology of COPD
Mortality for COPD has been increasing ever since while other diseases have decreasing
mortalities. COPD is the fourth leading cause of death in the United States. COPD also account
for the death of 125, 000 Americans every year. Mortality from COPD among women has
increased, and in 2005, more women than men died for COPD.

Pathophysiology of COPD
COPD is a complex syndrome comprised of airway inflammation, mucociliary dysfunction and
consequent airway structural changes.1
Airway inflammation
COPD is characterized by chronic inflammation of the airways, lung tissue and pulmonary blood
vessels as a result of exposure to inhaled irritants such as tobacco smoke.
The inhaled irritants cause inflammatory cells such as neutrophils, CD8+ T-lymphocytes, B cells
and macrophages to accumulate. These inflammatory mediators sustain the inflammatory
process and lead to tissue damage as well as a range of systemic effects. The chronic
inflammation is present from the outset of the disease and leads to various structural changes in
the lung which further perpetuate airflow limitation.
Structural changes
Airway remodeling in COPD is a direct result of the inflammatory response associated with
COPD and leads to narrowing of the airways. Three main factors contribute to this: peribronchial
fibrosis, build-up of scar tissue from damage to the airways and over-multiplication of the
epithelial cells lining the airways.

Mucociliary dysfunction

Enlarge of the mucous glands that line airway walls in the lungs, causing goblet cell metaplasia
and leading to healthy cells being replaced by more mucus-secreting cells. Additionally,
inflammation associated with COPD causes damage to the mucociliary transport system which
is responsible for clearing mucus from the airways. Both these factors contribute to excess
mucus in the airways which eventually accumulates, blocking them and worsening airflow

References

1. Agusti A. COPD, a multicomponent disease: implications for management. Respir Med

2005;99:670-82.
2. Barnes, PJ. Immunology of asthma and chronic obstructive pulmonary disease. Nat Rev
Immunol 2008;8:183-92.
3. Chung KF. The role of airway smooth muscle in the pathogenesis of airway remodelling
in COPD. Proc Am Thorac Soc 2005;2:347-54.
4. Laperre TS, Sont JK, van Schadewijk A, et al. Smoking cessation and bronchial
epithelial remodelling in COPD: a cross-sectional study. Respir Res 2007;8:85-93.

5. Danahay H & Jackson AD. Epithelial mucus-hypersecretion and respiratory disease.

Curr Drug Targets Inflamm Allergy 2005;4:651-64.