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