70 yrs old male came with complaints of shortness of breath since morning.

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan.


 70 yrs old male came with complaints of shortness of breath since morning, productive cough since 2-3 months, which got relieved with medications.

Patient was apparently asymptomatic till last night when he had alcohol last night, exposed to cold environment, following which he had SOB this morning, not decreased with inhalers, taken to RMP outside where nebulization kept and the symptoms decreased and he returned home, recurrence of symptoms at 5:00 pm, pt shifted here.

No c/o pedal edema, orthopnea, PND 

H/o similar episodic complaints since 5-6 yrs; increased since 1yr on exposure to cold

He is on inhalers ( salbutamol 100mcg/dose) daily use.


Past history:-

H/O HTN since 5yrs.

H/O ?TURP 5 yrs back; for progressive decreased urine output. 

No H/O DM, Asthma, CAD, Epilepsy, TB. 


VITALS

BP- 120/80 mmHg

PR- 122 BPM.

RR-30CPM

Temp- afebrile

Spo2- 85% at RA.


GENERAL EXAMINATION:-

Patient was conscious, coherent, cooperative with place, person and time. 

No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.

SYSTEMIC EXAMINATION:-

CVS-S1S2+.

RS- S1S2+, wheeze present on all left side.

P/a - soft,non tender

CNS- NAD


INVESTIGATIONS:-







Provisional diagnosis:- 

Acute exacerbation of COPD with H/O COPD

Treatment:- 

Inj hydrocortisone 100MG/IV/BD.

Nebulization with budecort, Ipravent 4th hourly.

Bipap intermittently ( over 30 min)

O2 inhalation ( according to spo2)

Inj PAN 40mg IV/OD.

Inj optineuron 1 amp in 100ml NS/IV/OD ( over 30 minutes)

Spo2,HR monitoring hourly.

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