Case Presentation

By:Asfa Ahmed Roll no:09-105

A 70 years old male,retired PIA officer,resident of bihar 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

History of presenting complaints:

According to the patient he was in his usual state of health.He has on and off cough and shortness of breath for past 20 years which has increased over past 1 week.Cough is severe,productive in nature,sputum is rusty brown in color,about 1 tbsp in quantity.Cough is worse in the morning.There is no hemoptysis,chest pain and no aggravating or relieving factors.Also,there are no seasonal variations.

It is associated with shortness of breath which is present on minimal activity and even on rest.It is increased on walking and resolves on lying down.He is able to complete senences but takes pauses in between as he gets breathless.There is no orthopnea,PND,cyanosis,palpitation and no use of accessory muscles for respiration.He has lost some weight over last few months.

He developed fever 3 days back which was acute in onset,continuous,high grade, documented 102 F,not associated with chills,and rigors.It relieves by taking antipyretics.There are no aggravating factors.It is associated with generalized weakness and dizziness.Fever is not associated with nausea,vomiting,abdominal pain,joint pain,rash,sore throat,night sweats and diarrhoea.

Past medical history: multiple hospital admissions due to similar complaints Known case of COPD(20 years), HTN(10 years),IHD(10 years), BPH(8 months) no history of blood transfusions Past surgical history: hernia operation cholecystectomy-11 years ago

Family history: non-consanginous marriage he has 3 children positive family history of HTN,DM and IHD. no family history of asthma,TB and cancers.

Personal history: sleep:disturbed appetite:decreased micturation:hesitency bowel habits:normal No known food or drug allergies He has a history of smoking for 40 years,used to smoke 1 pack per day i.e 40 pack years.He left smoking 4 years ago. He takes tobacco pan 6-8 times in a day

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)

Socioeconomic history: lives in his own house with 2 people uses boiled water all basic facilities available

Review of systems

Repiratory system:

cough + Sputum + Hemoptysis Hoarseness of voice Wheeze + snoring Day time somnolence

Cardiovascular system:

Chest pain Shortness of breath + Orthopnea PND Oedema Palpitation Claucidation

Genitourinary system:

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

Gastrointestinal tract:

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

Neurological:

Headache Dizzines + Vertigo Deafness Fits Memory Numbness in arms and legs

Hematological: Bruises Epistaxis Gum bleeding

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

Endocrine:

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

General physical examination

An elderly male,well oriented in time,person and place,sitting on bed,breathless. Vitals pulse:85/min,regular R/R:20 breaths/min BP:100/60 mmHg Temp:100F

Pallor + Jaundice Clubbing Cyanosis Dehydration Pedal edema JVP Lymph nodes Thyroid

Respiratory system examination

Inspection Equal movement of chest on both sides Chest elliptical in shape Abdomino thoracic type of breathing

Palpation

No tenderness,no swelling No tracheal deviation Apex beat palpable at 5th ICS midclavicular line Tactile vocal fremitus normal

Percussion

Percussion note resonant Normal vesicular breathing B/L equal air entry Coarse crackles in middle and lower zone B/L wheeze present on auscultation

Auscultation

Cardiovascular examination
Inspection No visible chest wall deformity Normal shape of chest No visible pulsations No scar marks Centrally placed trachea Apex beat palpable in 5th ICS midclavicular line No parasternal heave,no thrill

Palpation

Percussion

____ S1+S2 audible No murmur No added sounds

Auscultation

Abdominal examination
Inspection Normal shape,not distended Umbilicus centerally placed,not inverted Equal movement of abdominal wall No visible pulsation,no visible peristalsis

Palpation

Soft,nontender No visceromegaly

Percussion

Liver span 12 cm Percussion note tympanic No shifting dullness

Auscultation

Gut sounds audible 2-3/min

CNS examination

GCS 15/15 MMSE 5/5 Cranial nerves:intact Sensory system:normal Motor system:
R upper limb L upper limb R lower limb Bulk Tone Power Reflexes normal normal 5/5 normal normal normal 5/5 normal normal normal 5/5 normal L lower limb normal normal 5/5 normal

Planters

downgoing

downgoing

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

Investigations

CBC Chest X Ray PFTs Sputum DR and c/s UCE ESR CRP Urine DR and c/s for urinary complaints U/S KUB and Prostate

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

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

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

Urine DR

Urine physical

Urine microscopy

Color-----------yellow Appearance--clear Ph------------7.0 Sp.graity----1.010 Albumin-----Ketones----Bilirubin-----negative Blood--------Nitrate-------Urobilinogen-normal

Urine chemical

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

Urine culture---no bacterial growth Blood cultureno 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

Xray

PFTs were not done

Final diagnosis

Acute exacerbation of COPD secondary to community acquired pneumonia CURB 65 2/5 PSI 95(high risk grade 4) MMRC grade 4 BODE Index?

Management

Give oxygen(avoid giving high dose) Nebulize with bronchodilators(salbutamaol/ipratropium) Give antibiotics for underlying bacterial infection(2nd generation macrolides/extended spectrum fluoroquinolones/cephalosporins 2 and 3rd generation) Assess dehydration and give IV fluids Give steroids Avoid opiates and sedatives