Skip to main content

ACUTE EXACERBATION OF COPD: 56 YEAR OLD MALE

 



THIS IS AN ONLINE E-LOG TO DISCUSS DE-IDENTIFIED HEALTH DATA OF OUR PATIENTS.


CASE PRESENTATION


CHIEF COMPLAINTS:

- Difficulty in breathing
- Cough for 15 days
 

HISTORY OF PRESENT ILLNESS:

- Patient was apparently asymptomatic for 15 days 
- He then developed Shortness of Breath of Grade 2, 
  which had no aggravating or relieving factors & was sudden in onset. 
- No positional & Diurnal variation

- History of weight loss (8 Kgs in 6 months)
- Loss of appetite for 15 days 
- No history of cold or fever



HISTORY OF PAST ILLNESS AND TREATMENT:

-K/C/O of Cerebrovascular accident 2 years back 
 (Not on medication for 3 months)
-K/C/O COPD 2 years back 
 (Used Formonide 400 mg with Spacer: used for 15 days & discontinued)
-N/K/C/O Hypertension, Diabetes Mellitus, Epilepsy, Asthma, Tuberculosis



PERSONAL HISTORY:

- Appetite: Lost
- Diet: Mixed 
- Bowel & Bladder Movements: Normal
- Allergies: None 
- Habits: Alcohol (Daily 90 ml for 40 years) Now just occasional 
             Smoking for 40 years (32 BD/Day) 


FAMILY HISTORY: insignificant 


GENERAL EXAMINATION:

-Pallor: Absent
-Cyanosis: Absent
-Clubbing: Absent
-Lymphadenopathy: Absent 
-Pedal Edema: Absent


-Vitals:
Blood Pressure: 110/80 mmHg
Pulse Rate: 86 bpm
Respiratory: 16CPM 
Temperature: Afebrile 
SPo2%: 98%



SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:
S1S2+
No murmurs present

RESPIRATORY SYSTEM:
Wheeze +
Dyspnoea + (Grade 2)

Inspection: 
Size and shape of chest: Barrel-shaped
Movement of chest: Respiratory rate- 18cpm Rhythm-Normal Type- Abdominothoracic 
                             Expansion: Bilaterally symmetrical 
Position of Trachea: Central 

Palpation:
No local rise in temperature, No tenderness 

Movement of chest:

                                                    Right                             Left

Supraclavicular:                    Symmetrical                             Symmetrical
Mammary:                             Symmetrical                            Symmetrical    
Inframammary:                      Symmetrical                             Symmetrical    
Axillary:                                  Symmetrical                         Symmetrical    
Infra Axillary:                          Symmetrical                            Symmetrical    
Suprascapular:                        Symmetrical                            Symmetrical    
Scapular:                                Symmetrical                             Symmetrical    
Infrascapular:                         Symmetrical                             Symmetrical    





PER ABDOMINAL EXAMINATION:

No abnormalities detected


CENTRAL NERVOUS SYSTEM:

No focal neurological deficit



INVESTIGATION:









DIAGNOSIS:

Acute Exacerbation of Chronic Obstructive Pulmonary Disease 
(Emphymatous) 

K/C/O Cerebrovascular Accident (2 years)




TREATMENT:

TAB. ECOSPIRIN - AV 75/10 PO/ OD /HS
SYP. GRILLINCTUS 10 ML PO/ TOD
NEB. WITH DUOLIN- 8th HOURLY & BUDECORT- 8th HOURLY
TAB. MONTAER LC-PO/HS
TAB. PULMOCLEAR PO/BD



 








 


Comments

Post a Comment

Popular posts from this blog

65 Y/O Pneumonia- AKI - DKA

​ 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 a diagnosis and treatment plan.  A 65 year old male patient, resident of Thurkapallem, shop keeper by occupation came to the OPD with chief complaints of Chief Complaints:   Fever since 6 days  Breathlessness since 3 days  History of Presenting Illness:  Patient was apparently asymptomatic 6 days back, then he developed cold and cough with expectorant (green, mucoid) which has now subsided.  He developed fever since 6 days, high grade, continuous and not associated with chills and rigour. Relieved on taking medications prescribed by local RMP.  Complaints of decreased appetite since 4 days. Shortness of breath since 3 days - Grade 2  No history of hemoptysis  No history of tightness in chest ...
Post a Comment
Read more

65 y/o Male Parient - Cellulitis

​This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box. A 65 year old male patient, resident of Nalgonda, weaver by occupation came to the OPD with  Chief Complaints:  Swelling of right leg since 5 days  Fever since 5 days  History of Presenting Illness:  He was apparently asymptomatic 5 days ago, then he developed increased swelling in right lower limb, sudden in onset, gradually progressive, (foot to thigh), associated with pricking type of pain, aggravated on walking and relieved on rest.  Associated with blisters on leg...
Post a Comment
Read more