Republic of the Philippines

CAGAYAN STATE UNIVERSITY

Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

PATIENT
ASSESSMENT
and
ELECTROCARDIOGRAM

CLINICAL CASE PRESENTATION

Submitted by:
Jelie Reyes

Ezekiel Leguiab

Miguel Angel Caber

John Manuel Albayalde

Axcel Bryan Delin Mauanay

Aira Shane Mabborang

Scyrhielle Gayzehl Ancheta

Submitted to:

MR. MARK KELWIN DAGUIAO, RTRP

APRIL, 2021
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

I. CLINICAL CASE (Case 15)

For the first time, Mr. Eks went to the pulmonary outpatient clinic, complaining of
shortness of breath and a productive cough. He confirmed that his coughing had recently
become more frequent and that he was coughing up thick, yellow sputum. His cough had
been present for many years, but it was “usually not a problem,” he said. In the mornings,
his cough has typically produced clear to white sputum. He'd been experiencing more
shortness of breath than normal lately and was now dyspneic at rest. He admitted to feeling
hot at times in recent days, but he had not taken his temperature with a thermometer. Chest
pain, hemoptysis, sinusitis, weight loss, asthma, night sweats, and chills were all denied by
him. For the past 30 years, Mr. Eks has confessed to smoking 2 1⁄2 packs of cigarettes a
day. He had tried to quit several times but had only been successful for 3 or 4 months each
time. His job as a machinist had exposed him to a lot of poisonous fumes. His father died
of emphysema at the age of 64, but he had a family history of lung disease. His mother,
who is 75 years old, is still alive and well. His 47-year-old sister is in good health, while
his 51-year-old brother has diabetes

II. DEMOGRAPHICS (Patient Profile)

Name: Mr. Eks

Gender: Male
III. CHIEF OF COMPLAINT

Shortness of breath (Dyspnea) and Productive cough

IV. HISTORY OF PRESENT ILLNESS
Mr. Eks confirmed that his coughing had recently become more frequent and that
he was coughing of thick, yellow sputum. In the mornings, his cough has typically
produced clean to white sputum. He'd been experiencing more shortness of breath than
normal lately and was now dyspneic at rest. He admitted to feeling hot at times in recent
days, but he had not taken his temperature with a thermometer. Chest pain, hemoptysis,
sinusitis, weight loss, asthma, night sweats, and chills were all denied by him.
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

V. PAST MEDICAL HISTORY

The patient has a history of cough

VI. FAMILY HISTORY

His father died of emphysema at the age of 64, but he had a family history of lung
disease. His mother, who is 75 years old, is still alive and well. His 47-year-old sister is
in good health, while his 51-year-old brother has diabetes.
VII. PERSONAL AND SOCIAL HISTORY

Mr. Eks has smoke for 75 pack-years.

VIII. OCCUPATIONAL HISTORY
He’s a machinist
IX. ENVIRONMENTAL EXPOSURE HISTORY

He was expose to a lot of poisonous fumes in his job’s environment.

X. REVIEW OF SYSTEMS
Cardiopulmonary System: Mr. Eks was coughing up thick with white sputum, and a
productive cough, Shortness of breath, Dyspneic at rest
XI. PHYSICAL EXAMINATION
✓ General Survey: Mr. Eks appears alert, oriented and cooperative.
✓ Salient Features: Productive cough, Dyspnea, sputum production
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

XII. DIFFERENTIAL DIAGNOSIS

Signs and Pneumonia Chronic bronchiectasis Upper

symptoms Bronchitis Airway cough
Dyspnea + + _ +

Chronic _ + + +
cough
Thick yellow + + + _
sputum
Dyspneic at + + _ _
rest
Feeling hot _ _ + _

XIII. WORKING DIAGNOSIS

Chronic Bronchitis

XIV. PATHOPHYSIOLOGY

The pathological foundation for CB is due to the over-production of mucus in response to

the inflammatory signals, this is known as mucous metaplasia. In COPD patients this
overproduction and hypersecretion due to the goblet cells and decreased the elimination of
mucus The mechanisms responsible for mucous metaplasia in COPD patients is associated
with the function of the T cells, although it is still poorly understood. It is believed to be
linked to end production of the Th2 inflammation cells while the cellular response is
thought to be attributed to the Th1 inflammation cells, both produce cytokines that have an
influence on mucus production associated with COPD patients. Mucus metaplasia causes
airflow obstruction by several mechanisms: it causes luminal occlusion; the thickening of
the epithelial layer intrudes on the airway lumen, and the mucus alters the airway surface
tension. These all leave the airway at a greater risk for collapsing and decreases the capacity
for airflow and gas exchange. It was also found that smokers with moderate COPD and CB
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

had a greater number of goblet cells in their peripheral airways, which increases the
potential of mucus in the lungs. It was found that as a greater number of small airways
were blocked with mucus the greater the severity of the disease

Sample Flowchart

XV. DIAGNOSTIC PROCEDURE/S

✓ Medical History- A detailed review of your symptoms and your medical
history.
✓ Pulmonary function testing — in this test, you’ll breathe into a machine that
measures the amount of air in your lungs. This lets your doctor assess the
function of your lungs to see how well they’re working.
✓ Spirometry test- it’s helpful in making a clinical diagnosis of COPD and it is
the primary tool for evaluating the severity of the condition.
✓ Blood tests- can provide your medical team with information about whether
you have an infection
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

✓ Chest X-ray — Chest X-rays can help confirm a diagnosis of chronic

bronchitis and rule out other lung problems.
✓ Sputum Examination — Analysis of cells in your sputum (mucus) can help
pinpoint the cause of some lung problems.

XVI. TREATMENT AND MANAGEMENT

• Bronchodilator Medications Inhaled as aerosol sprays or taken orally,

bronchodilator medications may help to relieve symptoms of chronic bronchitis
by relaxing and opening the air passages in the lungs.
• Steroids Inhaled as an aerosol spray, steroids can help relieve symptoms of
chronic bronchitis.
• Antibiotics may be used to help fight respiratory infections common in people
with chronic bronchitis.
• Therapy As a patient's disease progresses, they may find it increasingly
difficult to breathe on their own and may require supplemental oxygen.
• Surgery Lung volume reduction surgery, during which small wedges of
damaged lung tissue are removed, may be recommended for some patients with
chronic bronchitis.
• Pulmonary Rehabilitation An important part of chronic bronchitis treatment
is pulmonary rehabilitation, which includes education, nutrition counseling,
learning special breathing techniques, help with quitting smoking and starting
an exercise regimen. Because people with chronic bronchitis are often
physically limited, they may avoid any kind of physical activity

Management

• Pulmonary rehabilitation, Give up smoking, Eat right and exercise, Get rest, Take
your medications correctly, Use oxygen appropriately, Retrain your breathing,
Avoid infections, Make and use an action plan Learn more about COPD

XVII. PREVENTION
“The best thing you can do to avoid developing COPD is to not smoke. If you’d like to
quit, smoking cessation programs can help you. Also, avoid any environment that has
poor air quality — air that has particles like dust, smoke, gases and fumes.”

References:

• https://www.nationaljewish.org/conditions/health-information/living-with-
copd/managing-copd
 Republic of the Philippines
CAGAYAN STATE UNIVERSITY
Andrews Campus, Tuguegarao City
COLLEGE OF ALLIED HEALTH SCIENCES
Department of Respiratory Therapy

• https://www.msdmanuals.com/professional/pulmonary-disorders/chronic-
obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-
pulmonary-disease-copd
• https://www.physio-pedia.com/Chronic_Bronchitis
• http://www.respelearning.scot/topic-2-assessment-and-common-lung-
diseases/common-lung-diseases/copd/chronic-bronchitis
• https://www.atsjournals.org/doi/full/10.1164/rccm.201210-1843CI
• https://www.ucsfhealth.org/conditions/chronic-bronchitis/treatment
• https://www.medicinenet.com/chronic_bronchitis/article.htm
• https://www.emedicinehealth.com/bronchitis/article_em.htm