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Case presentation

RVS

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PATIENT IDENTIFACTION

Name : Gopalnathan A/L Velupillai

Age : 72 years old

Sex : Male

Race :ndian

!ard : !ard 2"

Address :#heras

$ate o% admission:7th $ecem&er 2'("$ate o% cler)ing :('th $ecem&er 2'("

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Chief complaint

• Gopalnathan A/ Vel!pillai" #$ %ear ol&

In&ian male" presente& to 'ospital (!ala!mp!r on #th Decem)er $*+," -ith

shortness of )reath at rest since ,pm on

.th Decem)er $*+,

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'istor% of Presentin0 Illness

• 1rGopal ha& )een e2periencin0 attac3sof )reathlessness for the past , %ears an&is !s!all% relie4e& )% inhaler )!t recent

attac3 sho-e& no impro4ement -ith theinhaler 'e -as -ell !ntil last -ee3" -henhe )e0an to e2perience shortness of)reath -hile l%in0 &o-n It starte& slo-l%" it

is 0ettin0 -orse" not associate& -ith-hee5in0 or an% so!n&" it is on an& offThere -as no a00ra4atin0 or relie4in0factor for shortness of )reath

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• There is no complaint of !sin0 three pillo-s

to sleep or a-a3e from sleep &!e to

)reathlessness Patient feel tire& for this

one -ee3" ho-e4er he &oes complaint ofloss of -ei0ht or loss of appetite Apart

from all these" patient &oes not ha4e hi0h

0ra&e fe4er" chest pain" palpitation" prof!ses-eatin0" na!sea or 4omitin0" )ilateral le0

s-ellin0 or a)&ominal s-ellin0

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• The attac3 also occ!rre& -ith a pro&!cti4e

co!0h -ith copio!s 0reenish sp!t!m

There is no histor% of haemopt%sis" fe4er"

ni0ht s-eats or chest pain Altho!0h

patient claime& that he ha& lost some

-ei0ht &!e to &ecrease of appetite" it -as

not si0nificant

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• 1rGopal is 3no-n to ha4e histor% of

&ia)etes for the past 6 %ears an& he -as

&ia0nose& -ith 7ronchial Asthma since

$**8 'e ha& no histor% of h%pertension

'e claime& compliance to all me&ications

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Re4ie- of s%stem

• No si0nificant s%stemic re4ie-

Past 1e&ical 'istor%9• , %ears a0o he -as &ia0nose& -ithP!lmonar% T!)erc!losis an& -as treate&for 6 months after -hich he &iscontin!e&

me&ications 'e also ha& a past histor% ofm!ltiple a&missions &!e to rec!rrentasthmatic attac3s

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Past S!r0ical 'istor%9• No histor% of an% s!r0eries

Dr!0 'istor%9• Spiri4a Ac!haler +8m0 OD• T Ne!lin $,* m0

• T Pre&nisolone 6*m0 OD• Formeterol T!)oinhaler $ p!ffs 7D• T A!0mentin .$,m0 stat then 7D• T Raniti&ine +,*m0 7D• IV 1a2olon +*m0• 1ist e2pectorant +,ml

• Ne)!li5er Com)i4ent . ho!rl%• 1etere& Dose Inhaler :1DI; Sal)!tamol• IV '%&rocortisone +**m0 TDS• T A5ithrom%cin ,**m0• T 7isol4en 8m0 TDS

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Con

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 Aller0ies9

• No (no-n Dr!0 Aller0ies

Social 'istor%9• 'e is a retire& -or3er from the 1!nicipal

Department" marrie& -ith , health% chil&ren an&c!rrentl% sta%in0 -ith his -ife 'e -as a chronicsmo3er for $, %ears an& smo3e& $ pac3ets per&a% :,* pac3= %ears; 'e ha& no histor% ofcons!min0 alcohol or illicit &r!0s

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Famil% 'istor%9

• 7oth father an& mother passe& a-a% &!eto ol& a0e an& ha& no histor% of comor)i&

illnesses

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Ph%sical E2amination9

General E2amination9

• Patient -as alert" conscio!s" pin3 an& fairl%h%&rate&

• Si0ns of respirator% &istress -ere presentPatient -as tach%pnoiec an& accessor% m!scles-ere !se& to )reathe :sternoclei&omastoi&"scalene an& plat%sma;

• There -as also in&ra-in0 of intercostal spacesan& inspirator% &escent of trachea :Camp)ell>ssi0n;

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Vital si0ns

• Temperat!re=6# ?C

• 7loo& press!re =+@./@* mm'0• P!lse rate =8 )eats per min!te" has a

re0!lar rh%thm an& normal character an&

4ol!me• Respirator% rate=$$ )reaths per min!te

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On 0eneral e2amination

• There -as no fin0er cl!))in0" le!3on%chia"

3oilon%chia" splinter haemorrha0e" flappin0

tremor" c%anosis" Ba!n&ice" pallor or 2anthelasma• Corneal arc!s -as present

• There -as no palpa)le l%mph no&e or ele4ate&

VP

• se of accessor% m!scles of respiration -as

seen

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Respirator% E2amination

Inspection• Patient -as in respirator% &istress• Chest e2pansion -as as%mmetrical &!e to

&ecrease& l!n0 mo4ement on the ri0ht si&e• There -ere si0ns of &roopin0 of sho!l&er to

the ri0ht si&e" hollo-in0 of s!pracla4ic!larfossa" infracla4ic!lar fossa an& s!prascap!lar

fossa• Trachea -as shifte& to the ri0ht si&e -ithprominence of ri0ht sternoclei&omastoi&:Trail>s si0n;

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Palpation

• There -as 0eneralise& &ecrease in 4ocal fremit!s

an& localise& increase in 4ocal fremit!s on the

!pper part of the chest• There -as &!llness to perc!ssion on the !pper

chest an& also localise& resonance -as note&

a!sc!ltation

• there -as &ecrease& 4ocalresonance -itha smallarea of increase& 4ocal resonance onthe !pperpar t of the chest

• 7ilateralen& inspirator% crepitations an& lo- pitche& )ronchial)reathin0 -ere hear&

• Post=t!ssi4e s!ction -as not elicite& since the patient -as illan& co!l& not co=operate m!ch

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 A!sc!lation• There -as &ecrease& 4ocal resonance

-ith a small area of increase& 4ocal

resonance on the !pper part of the chest• 7ilateral en& inspirator% crepitations an&

lo- pitche& )ronchial )reathin0 -erehear&

• Post=t!ssi4e s!ction -as not elicite& sincethe patient -as ill an& co!l& not co=operate m!ch

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Car&io4asc!lar E2amination9

• Car&io4asc!lar s%stem -as clinicall%

normal e2cept for the fact that heart

so!n&s -ere hear& e4en -ell on

a!sc!ltation of the ri0ht a2illar% re0ion

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In4esti0ation

F!ll )loo& co!nt

• increase in -)c co!nt

• &ecrease in 1C' 4al!es• re&!ce in %m 4al!es

7!se an& creatinine

• so&i!m an& potassi!m le4els &ecreasei4er f!nction test =normal

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• Fastin0 ser!m lipi&= normal

Coa0!lation test

• increase in PT an& INRFastin0 )loo& 0l!cose

• increase in fastin0 )loo& s!0ar 

7loo& 0asIncrease in p' an& pO$

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In4esti0ations

Chest 2=ra%• Trachea is shifte& to the ri0ht si&e of the

l!n0

• There is also a prominent &ecrease of theri0ht l!n0 4ol!me compare& to the left l!n0

•  Apical fi)rosis -ith m!ltiple ca4ities can )eseen on the ri0ht l!n0

• There is tentin0 of the &iaphra0m on theri0ht si&e Costophrenic an0le is sharp-hich is normal

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