25 QUESTIONS TO MAKE A DIAGNOSIS An elderly man, 82 years old, presented with

cough for one week and breathlessness for one

day.
Did he have fever? No
Is the cough productive of sputum? Yes, mucoid sputum
Does he smoke? Yes, he is a smoker (40 pack years)
Has he had any health problems in the past? Yes. Was diagnosed with hypertension,
ischemic heart disease and congestive cardiac
failure earlier.
Was he taking any medication prior to this Yes. Hydrochlorothiazide, simvastatin, MDI
presentation? budesonide, MDI ipratropium with fenoterol
and MDI salbutamol
Did he take any medicines for his cough and Yes. He took salbutamol, budesonide and
breathlessness during this one week? ipratropium-fenoterol by metered dose
inhalers.
What was his pulse rate on presentation? 74/min and regular
What was his blood pressure? 135/66mm Hg
What was his temperature? 37 degrees centrigrade
What was his oxygen saturation? 99% while being given oxygen by nasal cannula
Was he conscious and alert? Yes
Did he have raised JVP? No
Did he have pedal oedema? No
Were there any abnormalities on auscultation No
of the heart?
Were there any abnormalities on auscultation Yes. Vesicular breath sounds with prolonged
of the lungs? expiration and generalised rhonchi
Were there any abnormalities on examination No
of abdomen?
Were there any abnormalities on full blood Hb was normal. Total leukocyte count was
count examination? 9200/uL with 87% neutrophils. Platelet count
normal.
What abnormal findings on x-ray chest? Diaphragms were flattened. The cardiac
shadow was more than 50% of the diameter of
the thorax.
Any abnormal findings on ECG? No. Normal sinus rhythm
What was his plasma glucose? Random capillary blood glucose 7.8mmol/L
What was his renal profile? Blood urea and Serum creatinine were both
elevated. Sodium and potassium were normal
What were his urinary findings? Albumin was detected. No microscopic
abnormalities
Does he have any difficulty in passing urine? He did not complain of any difficulty
Was an examination of the prostate done? No
How was he treated in hospital? Nebulised ipratropium and salbutamol. IV
hydrocortisone initially, followed by tab
prednisolone. Augmentin and azithromycin
tablets. Oxygen was also given.
Acute exacerbation of COPD. The diagnosis of COPD is because the patient is on medication appropriate for COPD, has prolonged
expiration and rhonchi in the lungs and flattening of diagphragm on x-ray chest.
He was diagnosed with hypertension but it is not certain if that diagnosis is still applicable because the BP is normal and
there is no mention of any antihypertensive medication.
He has said that he has IHD but there is no objective evidence. The ECG is normal and he does not seem to be on any
medicines appropriate for IHD
He may have corpulmonale because he has cardiomegaly on x-ray chest and a past history of having been diagnosed with
CCF and being prescribed hydrochlorothiazide.
He also has a respiratory infection (may or may not be pneumonia) because he has been prescribed antibiotics, has cough
with sputum and neutrophila in the blood.
Chronic kidney disease is likely because urea and creatinine are elevated and there is albumin in the urine
From your responses: AKI is not my first consideration for his elevated urea and creatinine because I do not see a context in
which AKI can occur (not dehydrated, not in cardiac failure now and not in sepsis). Does he have glucose intolerance or diabetes? His
random plasma glucose is not high enough to diagnose diabetes but it does not rule out that either. So, without a repeat value (or
preferably a fasting value), I refrained from commenting on it.