Case Presentation Medicine

8/12/2019 Case Presentation Medicine

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Case Presentation

By:Asfa AhmedRoll no:09-105


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A 70 years old male,retired PIA officer,resident ofbihar colony,presented to ER on 19 December,2013.

He is a known case of HTN,DM,IHD,BPH and

COPD.

Presenting complaints: on and off cough present since last 20 years shortness of breath increased over past 1 week fever 3 days


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History of presenting complaints:

According to the patient he was in his usual state ofhealth.He has on and off cough and shortness of

breath for past 20 years which has increased overpast 1 week.Cough is severe,productive innature,sputum is rusty brown in color,about 1 tbsp inquantity.Cough is worse in the morning.There is no

hemoptysis,chest pain and no aggravating orrelieving factors.Also,there are no seasonalvariations.


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It is associated with shortness of breath which ispresent on minimal activity and even on rest.It isincreased on walking and resolves on lying down.He

is able to complete senences but takes pauses inbetween as he gets breathless.There is noorthopnea,PND,cyanosis,palpitation and no use ofaccessory muscles for respiration.He has lost some

weight over last few months.


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He developed fever 3 days back which was acute inonset,continuous,high grade, documented 102 F,notassociated with chills,and rigors.It relieves by taking

antipyretics.There are no aggravating factors.It isassociated with generalized weakness anddizziness.Fever is not associated withnausea,vomiting,abdominal pain,joint pain,rash,sore

throat,night sweats and diarrhoea.


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Past medical history:multiple hospital admissions due to similarcomplaintsKnown case of COPD(20 years),

HTN(10 years),IHD(10 years), BPH(8 months)no history of blood transfusions

Past surgical history:hernia operationcholecystectomy-11 years ago


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Personal history:sleep:disturbedappetite:decreasedmicturation:hesitencybowel habits:normal

No known food or drug allergiesHe has a history of smoking for 40 years,used to

smoke 1 pack per day i.e 40 pack years.He leftsmoking 4 years ago.He takes tobacco pan 6-8 times in a day


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Current medications:Tab.Ascard(anti-platelet)Tab.Nuberol(analgesic)Cap.ceporex(cephalexin)Tab.motilium(domeperidone)Tab Xanax(alprazolam)Tab.xatral(alfuzosin-alpha blocker0

Tab.proscar(finestride-for BPH)


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Socioeconomic history:lives in his own house with 2 peopleuses boiled waterall basic facilities available


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Review of systems

Repiratory system:

cough + Sputum + Hemoptysis Hoarseness of voice Wheeze +

snoring

Day time somnolence


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Cardiovascular system:

Chest pain Shortness of breath + Orthopnea PND Oedema

Palpitation

Claucidation


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Genitourinary system:

Dysuria + Frequency +(6-8 times) Urgency Hesitancy + Nocturia +(3-4 times)

Incontinence

Hematuria


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Gastrointestinal tract:

Indigestion Heart burn Jaundice Dysphagia Abdominal pain Nausea/vomiting Diarrhea- Constipation Malena Weight loss-


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Neurological:

Headache Dizzines + Vertigo Deafness Fits

Memory

Numbness in arms and legs


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Hematological: Bruises Epistaxis Gum bleeding

musculoskeletal: Joint pain Joint swelling/stiffness Skin rash Dry mouth Back or neck pain


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Endocrine:

Swelling in neck Tremors Hot and cold intolerance Sweating Change in appearance of skin/hair/voice


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General physical examination

An elderly male,well oriented in time,person andplace,sitting on bed,breathless.

Vitals pulse:85/min,regular R/R:20 breaths/min BP:100/60 mmHg

Temp:100F


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Pallor +Jaundice Clubbing Cyanosis Dehydration Pedal edema JVP

Lymph nodes

Thyroid


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Respiratory system examination

Inspection

Equal movement of chest on both sides

Chest elliptical in shapeAbdomino thoracic type of breathing

Palpation

No tenderness,no swellingNo tracheal deviation

Apex beat palpable at 5 th ICS midclavicular lineTactile vocal fremitus normal

Percussion Percussion note resonant

Auscultation

Normal vesicular breathingB/L equal air entryCoarse crackles in middle and lower zoneB/L wheeze present on auscultation


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Cardiovascular examination

Inspection

No visible chest wall deformity

Normal shape of chestNo visible pulsationsNo scar marks

Palpation

Centrally placed trachea Apex beat palpable in 5 th ICS midclavicular line

No parasternal heave,no thrill

Percussion ____

Auscultation

S1+S2 audibleNo murmurNo added sounds


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Abdominal examination

Inspection

Normal shape,not distendedUmbilicus centerally placed,not invertedEqual movement of abdominal wallNo visible pulsation,no visible peristalsis

PalpationSoft,nontenderNo visceromegaly

PercussionLiver span 12 cmPercussion note tympanic

No shifting dullness

Auscultation Gut sounds audible 2-3/min


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CNS examinationGCS 15/15

MMSE 5/5Cranial nerves:intactSensory system:normalMotor system:

R upper limb L upper limb R lower limb L lower limb

Bulk normal normal normal normal

Tone normal normal normal normal

Power 5/5 5/5 5/5 5/5

Reflexes normal normal normal normal

Planters - - downgoing downgoing


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Differential diagnosis Pneumonia with acute exacerbation of COPD Acute exacerbation of COPD Congestive heart failure Bronchiectasis Chronic asthma


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Investigations

CBCChest X RayPFTsSputum DR and c/sUCEESRCRP

Urine DR and c/s for urinary complaintsU/S KUB and Prostate


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CBC Hb ------------------10.0 Red cell count----3.4 Hct--------------------30 MCV------------------88

MCH------------------29 MCHC----------------33 Platelet count-------202 ESR>100

Total WBC-----------10.3 Neutrophils------------65 Lymphocytes----------25 Monocytes--------------8 Eosinophils-------------2


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Urea-----------23Creatinine---0.99CRP-----------97.73

Electrolytes Sodium--------145 Potassium----4.3 Chloride-------107 Bicarbonate---22


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Urine DRUrine physical Color-----------yellow Appearance--clearUrine chemical Ph------------7.0 Sp.graity----1.010 Albumin------ Ketones----- Bilirubin------ negative Blood--------- Nitrate-------- Urobilinogen-normal

Urine microscopy RBC----------occasional Leukocytes-occasional Epithelial cell-nil Bacteria ----nil Yeast cells----nil Mucus----------nil Casts --------nil Crystal---------nil


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Urine culture---no bacterial growthBlood culture no bacterial growth

AFB---smear negative for acid fast bacilli

U/S KUB and prostate Enlarged prostate measures 5.2-4.2-4.2 cm with an

approximate volume of 47 mls.No focal mass. Post void residual volume of urine is 19 mls No other anomaly seen


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Xray


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PFTs were not done


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Final diagnosis

Acute exacerbation of COPD secondary tocommunity acquired pneumoniaCURB 65 2/5

PSI 95(high risk grade 4)MMRC grade 4

BODE Index?


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ManagementGive oxygen(avoid giving high dose)Nebulize withbronchodilators(salbutamaol/ipratropium)Give antibiotics for underlying bacterial infection(2 nd

generation macrolides/extended spectrumfluoroquinolones/cephalosporins 2 and 3 rd generation)

Assess dehydration and give IV fluids

Give steroids Avoid opiates and sedatives


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