A 60 years old Male with SOB

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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-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 60 year old Male came (on 18/10/22)with 

c/o cough since 6 days 

C/o SOB since 6 days 


HOPI- 

Pt was apparently asymptomatic 1 year back Then he had fever with thrombocytopenia,from then he started having SOB ,was admitted in hospital and got treated 

Now after 1 year pt complaints of 

Cough with sputum which is white in color ,mucoid,non foul smelling,non blood stained 

Cough is more during night 

C/o SOB since 3 months 

SOB increases on lying down 

Grade-

Palpitations +

Sweating +

A/w fever 

Past history:

N/k/c/o HTN,DM,Asthma,Epilepsy ,TB

H/o surgery to spine


Personal history :

Diet mixed 

Appetite normal 

Bowel and bladder movements regular 

Sleep disturbed (because of cough)

Smokes 9 beedis per day (since 50 years)

Smokes cigarette occasionally 

Drinks toddy in summers

Drinks alcohol occasionally 





General examination 

Pt is c/c/c well oriented to time ,place and person 

Well built and nourished 

No pallor,icterus ,clubbing ,generalised lymphadenopathy 

Vitals on admission -

BP-170/60mmHg

PR-50bpm

RR-32 cpm

Landolfi’s sign :

https://youtu.be/6WA2RR-ssBE


CVS-

S1S2 +

Pan systolic murmur 

JVP elevated


RS -

Inspection -

Trachea appears to be central 

 Pattern of breathing -abdominal 

Shape of chest -barrel 


Palpation -

Inspectors findings confirmed 

Trachea central in position 

AP:Transverse =1:1.3

Bilateral air entry +

No retractions


Percussion -resonant note heard 

Auscultation-wheeze +

Basal crepts+

PA :soft non tender 

No organomegaly 


CNS:higher motor functions intact 

No focal neurological deficit 


Investigations:

Serology-negative

FBS-78 mg/dL

PLBS-108 mg/dL

Blood urea -31 

Serum creatinine-1.0

Na+ 145

K+ 3.8

Cl- 106

Ca :0.83


Hb-11.2 gm/dL

TLC-6,700 

Neutrophils-57

Lymphocytes-33

Eosinophils -1

Monocytes-9

Basophils-0


LFT

TB-0.57

DB-0.18

AST-28

ALT-25

ALP-128


TP-5.9

Albumin -3.83

A/G-1.85

FBS-78

PLBS-108


HbA1c-6.4


Cxray-

18-10-22


20-10-22


PFT :

20/10/22



21/10/22-



2decho-





Diagnosis:


Acute exacerbation of COPD (chronic bronchitis >emphysema ) with right heart failure 

GOLD-C

CAT score -7



Treatment :

(18/10/22)

Neb IPRAVENT 1 resp P/N 8th hourly 

O2 supplementation (if SpO2 <92%)on RA

Tab DOLO 650 mg /PO/SOS

GRBS monitoring 

BP/PR/RR/SpO2 4th hourly 



(19/10/22)


S

SOB still present 

Cough with sputum 

No fever spikes 


O

Pt is C/C/C

BP-130/80mmHg

PR-52bpm regular rate rhythm

RR-28cpm

SpO2-98on RA

CVS -S1S2 +

PSM at mitral ,aortic 

S2 loud 

RS -wheeze + (expiratory)

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)

With RTHF 


P


Nebulistation IPRAVENT 1 Respules p/n 8th hourly 

O2 supplementation SPO2<92% on RA

Tab DOLO 650/PO/SOS

Tab Telma 40 /PO/OD

BP/PR/RR 4th hourly


(20/10/22)



S

SOB still present 

Cough with sputum 

No fever spikes 


O

Pt is C/C/C

BP-100/60 mmHg

PR-48bpm regular rate rhythm

RR-26cpm

SpO2-92 on RA

CVS -S1S2 +

PSM at mitral ,aortic 

S2 loud 

RS -wheeze + (expiratory)

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)

With RTHF > LTHF


P


Inj.DERIPHYLLIN 100 mg/IV/BD

Nebulistation IPRAVENT 2 Respules QID

Neb BUDECORT 8th hourly 

O2 supplementation SPO2<92% on RA

Tab DOLO 650/PO/SOS

Tab Telma 40 /PO/OD

Tab .LASIX 40mg /PO/BD(8am—x—4pm)

SYP.ASCORYL 10mL/PO/TID

BP/PR/RR 4th hourly



(21/10/22)

Amc bed 2

S

SOB present (but reduced )

Cough with sputum 

No fever spikes 

Decreased sleep at night 


O

Pt is C/C/C

BP-90/80 mmHg

PR-60 bpm regular rate rhythm

RR-26cpm

SpO2-97 on RA

CVS -S1S2 +

PSM 

JVP raised 

RS -wheeze + (expiratory)

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)



P


Inj.DERIPHYLLIN 100 mg/IV/BD

Nebulistation IPRAVENT 2 Respules QID

Neb BUDECORT 8th hourly 

O2 supplementation SPO2<92% on RA

Tab Telma 20 mg PO/OD

Tab .LASIX 40mg /PO/BD(8am—x—8pm)

Tab.Azithromycin 500 mg PO/OD(d1)

SYP.ASCORYL 10mL/PO/TID

BP/PR/RR 4th hourly


(22/10/22)

S

SOB present (reduced )

Cough with sputum 

No fever spikes 


O

Pt is C/C/C

BP-100/60 mmHg

PR-66bpm regular rate rhythm

RR-26cpm

SpO2-97 on RA

CVS -S1S2 +

JVP raised 

RS -wheeze + (expiratory)

Diffuse B/L 

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)



P


Inj.DERIPHYLLIN 100 mg/IV/BD

Nebulistation IPRAVENT 2 Respules QID

Neb BUDECORT 8th hourly 

O2 supplementation SPO2<92% on RA

Tab Telma 20 mg PO/OD

Tab .LASIX 40mg /PO/BD(8am—x—8pm)

Tab.Azithromycin 500 mg PO/OD(d2)

SYP.ASCORYL 10mL/PO/TID

BP/PR/RR 4th hourly 





23/10/22


S

SOB present 

Cough with sputum 

No fever spikes 


O

Pt is C/C/C

BP-100/60 mmHg

PR-52bpm regular rate rhythm

RR-28cpm

SpO2-97 on RA

CVS -S1S2 +

RS -wheeze + (expiratory)

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)



P


Inj.DERIPHYLLIN 100 mg/IV/BD

Nebulistation IPRAVENT 2 Respules QID

Neb BUDECORT 8th hourly 

O2 supplementation SPO2<92% on RA

Tab Telma 20 mg PO/OD

Tab .LASIX 40mg /PO/BD(8am—x—8pm)

Tab.Azithromycin 500 mg PO/OD(D3)

SYP.ASCORYL 10mL/PO/TID

BP/PR/RR 4th hourly 



24/10/22:



S

SOB present(reduced )

Cough with sputum 

No fever spikes 


O

Pt is C/C/C

BP-110/60 mmHg

PR-56bpm regular rate rhythm

RR-28cpm

Temp-97.2 F

CVS -S1S2 +

GRBS-123 mg/dL

RS -wheeze + (expiratory)

PA-soft non tender 

No organomegaly 


A

Acute exacerbation of COPD (chronic bronchitis >emphysema)



P


Inj.DERIPHYLLIN 100 mg/IV/BD

Nebulistation IPRAVENT 2 Respules QID

Neb BUDECORT 8th hourly 

O2 supplementation SPO2<92% on RA

Tab Telma 20 mg PO/OD

Tab .LASIX 40mg /PO/BD(8am—x—8pm)

Tab.Azithromycin 500 mg PO/OD(D4)

SYP.ASCORYL 10mL/PO/TID

BP/PR/RR 4th hourly 



25/10/22

Advice at discharge 

-Absolute smoking cessation 

-Salt (<1tsp/day)and water(<1.5lit/day)restriction 

-MDI spacer TIOVA 1 puff BDx2months

-Tab Deriphyllin 100mg PO/BD for 15days

-Tab Azithromycin 500 mg PO/OD for 1week 

-Tab Telma 20mg PO/OD

-Tab Lasix 40mg PO/BD(8am——-4pm)




Discharge summary :


























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