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

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

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

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

e 40 pack years. He takes tobacco pan 6-8 times in a day .He left smoking 4 years ago.used to smoke 1 pack per day i. 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.

proscar(finestride-for BPH) .ceporex(cephalexin) Tab.motilium(domeperidone) Tab Xanax(alprazolam) Tab. Current medications: Tab.Nuberol(analgesic) Cap.Ascard(anti-platelet) Tab.xatral(alfuzosin-alpha blocker0 Tab.

 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 – .

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

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

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 .Respiratory system examination Inspection Equal movement of chest on both sides Chest elliptical in shape Abdomino thoracic type of breathing Palpation No tenderness.

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 .

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

0 Red cell count----3. • • • • • • • • • CBC Hb ------------------10.3 • • • • Neutrophils------------65 Lymphocytes----------25 Monocytes--------------8 Eosinophils-------------2 .4 Hct--------------------30 MCV------------------88 MCH------------------29 MCHC----------------33 Platelet count-------202 ESR>100 Total WBC-----------10.

99 CRP-----------97.   Urea-----------23 Creatinine---0.3 Chloride-------107 Bicarbonate---22 .73 Electrolytes • • • •  Sodium--------145 Potassium----4.

Urine DR  Urine physical •  Urine microscopy • • Color-----------yellow Appearance--clear Ph------------7.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 .0 Sp.

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 .2-4.  Urine culture---no bacterial growth Blood culture—no bacterial growth AFB---smear negative for acid fast bacilli   • • • U/S KUB and prostate Enlarged prostate measures 5.

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 .