56 YEAR OLD MALE WITH ACUTE EXCERABATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE PRESENTATION 

CHIEF COMPLAINTS: 

 . DIFFICULTY IN BREATHING SINCE 15 DAYS 

.COUGH SINCE  15 DAYS 

HISTORY OF PRESENT ILLNESS : 

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED SOB OF GRADE II , SUDDEN IN ONSET , NO AGGREVATING  AND RELIEVING FACTORS . ASSOCIATED WITH COUGH SINCE 15 DAYS  . NO  H/O POSITIONAL VARIATION. NO H/O DIURNAL VARIATION . 

H/O WEIGHT LOSS (8 KGS SINCE 6 MONTHS)

.LOSS OF APPETITE SINCE 15 DAYS , NO H/O FEVER, NO H/O COLD . NO H/O PALPITATIONS/ CHEST PAIN 

PAST AND TREATMENT HISTORY:

K/C/O CVA 2 YEARS BACK (NOT ON MEDICATION SINCE 3 MONTHS)

K/C/O COPD 2 YEARS BACK (USED FORMONIDE 400 MG  WITH SPACER - USED FOR ONLY 15 DAYS AND STOPPED) 

N/K/C/O HYPERTENSION, DM, EPILEPSY, ASTHMA, TB, CAD 

PERSONAL HISTORY : 

APPETITE - LOST 

DIET -MIXED

BOWEL AND BLADDER: REGULAR 

ALLERGY: NO ALLERGY 

HABITS: 

PAST - DAILY 90 ML FOR 40 YEARS  : NOW OCCASIONAL 

SMOKING SINCE 40 YEARS (32 BD/ DAY)

FAMILY HISTORY: NOT SIGNIFICANT 

GENERAL EXAMINATION:

 PALLOR ABSENT

 CYANOSIS-ABSENT

 CLUBBING-ABSENT

 LYMPHADENOPATHY-ABSENT

 PEDAL EDEMA -ABSENT 

 VITALS 

 BP: 110 / 80 MMHG 

PULSE RATE: 86 BPM

 RESPIRATORY: 16 CPM

 TEMPERATURE: AFEBRILE 

SPO2: 98%

SYSTEMIC EXAMINATION :

 CARDIOVASCULARSYSTEM :

 S1S2 +

 NO THRILLS 

NO MURMURS 

 RESPIRATORY SYSTEM :

 WHEEZE +(MAMMARY/ ISC/IM/IA )

  DYSOPNEA +( GRADE II)

VESICULAR BREATHE SOUNDS HEARD 

INSPECTION: 

SIZE AND SHAPE OF CHEST :  BARREL SHAPE

MOVEMENT OF CHEST:  

       1) RESPIRATORY RATE: 18 CPM 

        2) RHYTHM: NORMAL

          3) TYPE OF BREATHING:              ABDOMINOTHORACIC

           4) EXPANSION OF CHEST: ( ANTERIOR AND POSTERIOR) - BILATERAL SYMMETRICAL.

ACCESSORY MUSCLE OF RESPIRATION : NOT WORKING .

POSITION OF TRACHEA: CENTRAL 

POSITION OF APEX BEAT :

PALPATION:

NO LOCAL RISE OF TEMPERATURE, NO TENDERNESS 

ALL INSPECTORY FINDINGS ARE CONFIRMED.

SYMMETRICAL IN ANTERIOPOSTERIOR AND TRANSVERSE DIRECTION.

MOVEMENT OF CHEST: 

                                                 RIGHT           LEFT 

SUPRACLAVICULAR :.    SYM.                      SYM

MAMMARY:.                     SYM                        SYM

INFRAMAMMARY :.          SYM.                      SYM

AXILLARY:.                          SYM.                      SYM

INFRA AXILLARY :.           SYM.                     SYM

SUPRASCAPULAR :.             SYM.                     SYM

SCAPULAR :.                   SYM.                             SYM

INFRASCAPULAR:.              SYM.                    SYM

 PER ABDOMINAL EXAMINATION :

NO ABNORMALITIES DETECTED 

CENTRAL NERVOUS SYSTEM:

NO FOCAL NEUROLOGICAL DEFICIT 

INVESTIGATION:

CHEST XRAY 

SERUM ELECTROLYTE 

RBS

LFT 

BLOOD UREA

ECG

DIAGNOSIS: 

 ACUTE EXCERABATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE ( EMPHYSEMATOUS ) (AE)

K/C/O CVA (2YRS BACK)

TREATMENT: 

TAB. ECOSPIRIN -AV 75/10 PO/ OD/HS 

SYP. GRILLINCTUS 10 ML PO/ TOD 

NEB. WITH DUOLIN -8 TH HOURLY AND BUDECORT -8 TH HOURLY

TAB. MONTAER LC- PO/ HS 

INJ. HYDROCORT 100 MG IV/ STAT 

TAB. PULMOCLEAR PO/BD

VITALS MONITORING 4 TH HOURLY 

22/12/22

TAB. ECOSPIRIN -AV 75/10 PO/ OD/HS 

SYP. GRILLINCTUS 10 ML PO/ TOD 

NEB. WITH DUOLIN -8 TH HOURLY AND BUDECORT -8 TH HOURLY

TAB. MONTAER LC- PO/ HS 

INJ. HYDROCORT 100 MG IV/ STAT 

TAB. PULMOCLEAR PO/BD

VITALS MONITORING 4 TH HOURLY