CASE PRESENTATION

Spurthi Shailendra
BMCRI
• Name: Mr. Abdul Waheed
• Age: 68 years
• Address: Rajajinagar, Bangalore
• Occupation: Tailor

• Date of Admission: 01.03.2020

• Date of Examination: 05.03.2020
CHIEF COMPLAINTS
• Cough with expectoration since 4 months
• Breathlessness since 4 months
• Bilateral lower limb swelling since 4 months
HISTORY OF PRESENTING ILLNESS
Patient complains of cough since the last 4 months. Insidious in onset,
progressive and associated with expectoration. Sputum is yellow in
colour, mucoid consistency, moderate amount (around 50ml/day), non
blood-tinged, not foul smelling, aggravated during the night.
He also complains of breathlessness since the last 4 months, insidious
in onset, progressive, initially experienced while climbing stairs but is
now present even after walking for a few minutes on level ground.
(MMRC grade 1 to 3). No history of orthopnea or PND
Patient complains of swelling of bilateral lower limbs since 4 months.
Insidious in onset. Initially he developed swelling upto the ankles
bilaterally, now having progressed upto his thighs. Swelling was
aggravated at the end of the day, relieved on elevation of the limbs.

Patient has no history of Fever, Hemoptysis.

No history of loss of weight or appetite.
No history of Chest pain.
PAST HISTORY

• Patient has had similar complaints of cough in the past but has no
history of previous hospitalisation for the same.
• Not a known case of Diabetes Mellitus, Hypertension, Tuberculosis,
Asthma.
FAMILY HISTORY
• No history of similar complaints in the family.
• No history of Tuberculosis, Bronchial asthma, Malignancy in members
of the family.
PERSONAL HISTORY
• Diet: Mixed
• Appetite: Normal
• Sleep: Disturbed (due to cough)
• Bowel and Bladder habits: Regular

• Patient is a chronic smoker since the last 45 years. 2packs of cigarattes per
day.
= 90 pack years (no.of packets per day X no. of years)
Smoking index= (cigarettes per day X no of years) = 40*45=1800
No other habits.
SUMMARY
A 68 year old gentleman, with a background of chronic cough since few
years, has developed cough with expectoration and breathlessness
since the last four months with swelling of lower limbs which has
gradually progressed.
My provisional diagnosis at the end of history, is that it could probably
be an Exacerbation of COPD with Cor Pulmonale
Differential Diagnosis
• Acute exacerbation of COPD
• Pulmonary TB with extrapulmonary TB
• Congestive heart failure with acute exacerbation
PHYSICAL EXAMINATION
An elderly male patient, well built and well nourished, conscious and
cooperative, well oriented to time, place and person.

VITALS:
• Pulse: 80beats per minute, regular, good volume, normal character
• Blood Pressure: 110/70 mmHg, measured in the right arm, in supine
position
• Respiratory Rate: 24 cycles per minute, Abdominothoracic
• Temperature: 38 C
HEAD TO TOE EXAMINATION
• Eyes: Bilateral Arcus Senilis present. Right eye esotropia
• No pallor, icterus, cyanosis, clubbing or lymphadenopathy.
• JVP
Raised- 12cm of blood, from sternal angle at 45degree inclination
Abdominojugular reflex present
• Bilateral lower limb edema upto thighs, Pitting, Grade 3
• Abdominal distension present
• No external markers of Tuberculosis present.
EXAMINATION OF RESPIRATORY SYSTEM
Upper Respiratory Tract:
• Nasal cavity: normal
• Oral cavity: normal
• Pharynx appears normal
EXAMINATION OF LOWER RESPIRATORY TRACT
INSPECTION
• Chest is elliptical in shape and bilaterally symmetrical
• Trachea appears to be central
• Apex beat cannot be visualised
• Use of accessory muscles of respiration present
• No dilated veins, scars or sinuses visible on chest wall
• Kyphoscoliosis or dropping of shoulder not present
• No indrawing of intercostal spaces
• Chest movements
Areas of Chest Wall Right Left

Anteriorly:
• Supraclavicular Appear to be
• Infraclavicular Reduced Reduced
• Mammary

Laterally:
• Axillary Reduced Reduced
• Infra-axillary

Posteriorly:
• Suprascaular Reduced Reduced
• Interscapular
• Infrascapular
PALPATION
• Inspectory findings are confirmed
• Trachea is central in position
• Apex beat palpable in 5th intercostal space lateral to midclavicular line
• No local raise of temperature
• Movements of chest:
Areas of Chest Wall Right Left
Anteriorly:
• Supraclavicular
• Infraclavicular Reduced Reduced
• Mammary
Laterally:
• Axillary Reduced Reduced
• Infra-axillary
Posteriorly:
• Suprascaular Reduced Reduced
• Interscapular
• Infrascapular
• Tactile Vocal Fremitus
Areas of Chest Wall Right Left

Anteriorly:
• Supraclavicular
• Infraclavicular Reduced Reduced
• Mammary

Laterally:
• Axillary Reduced Reduced
• Infra-axillary

Posteriorly:
• Suprascaular Reduced Reduced
• Interscapular
• Infrascapular
• Measurements:
AP diameter= 25 cm
Transverse diameter= 30cm (ratio= 0.83)
Chest circumference (on expiration)= 98cm
Chest circumference ( on inspiration)= 100cm
Chest expansion= 2cm
Right Hemithorax= 50cm (expansion 1cm)
Left Hemithorax=50cm (expansion 1cm)
PERCUSSION
Direct: Right clavicle Left clavicle
Resonant Resonant

Indirect: Areas of Chest Wall Right Left

Anteriorly:
• Supraclavicular
• Infraclavicular Resonant Resonant
• Mammary

Laterally:
• Axillary Resonant Resonant
• Infra-axillary

Posteriorly:
• Suprascaular Resonant Resonant
• Interscapular
• Infrascapular
AUSCULTATION
• Character of breath sounds : Normal Vescicular breath sounds
• Intensity of breath sounds:
Areas of Chest Wall Right Left
Anteriorly:
• Supraclavicular
• Infraclavicular Diminished Diminished
• Mammary

Laterally:
• Axillary Diminished Diminished
• Infra-axillary

Posteriorly:
• Suprascaular Diminished Diminished
• Interscapular
• Infrascapular
• No Added sounds present
• Vocal Resonance – Diminished in all areas
EXAMINATION OF OTHER SYSTEMS
• CVS- S1S2 heard in all areas. No murmurs audible

• Abdominal examination-
Generalised distension of abdomen. Tenderness in right
hypochondrium region. No hepatomegaly. Shifting Dullness present

• CNS- Conscious and well oriented. No focal neurological deficits

PROVISIONAL DIAGNOSIS
A 68 year old gentleman who is a chronic smoker presented with
history of cough with expectoration, breathlessness and edema of
lower limbs with restriction of activity due to shortness of breath. On
examination, he has a raised JVP, reduced movements in all regions of
the chest, hyper-resonance on percussion and reduced air entry on
auscultation. He has bilateral grade 3 pitting edema and ascites. Based
on history and examination findings, I would like to make a provisional
diagnosis of Exacerbation of COPD, predominantly Emphysema, with
Cor Pulmonale.
DIFFERENTIAL DIAGNOSIS
• Tuberculosis
• Congestive Cardiac Failure
MANAGEMENT : INVESTIGATIONS
• Complete blood count
• Blood Sugar levels
• ESR
• Renal function tests
• Liver function tests

• Chest X-ray
• Sputum Examination- Microscopy/Culture/antibiotic sensitivity
• Pulmonary Function Tests, Spirometry
• Arterial blood gas analysis
• ECG
XRAY

• Hyperinflation bilaterally
• Tubular heart
• Flattened diaphragm
• Enlargement of pulmonary
trunk
• Increased bronchovascular
markings
 MANAGEMENT: TREATMENT
• Smoking cessation
• Oxygen therapy: Controlled oxygen at 24-28%
Aim of maintaining PaO2 > 60mmHg or SaO2>90%

• Bronchodilators: Nebulised Short acting B2 agonist + Anticholinergic agent ( Salbutamol+Ipratropium)

• Oral Prednisolone: 30mg for 10-14 days

• Antibiotics: If there is history of purulent sputum or change in sputum volume, or based on sputum culture.

• Non Invasive Positive Pressure Ventilation (NIPPV): Indication- persistent acidosis/hypercapnia inspite of medical therapy
and oxygenation, Respiratory Failure

• Invasive Mechanical ventilation: NIV failure, impaired mental status

• For edema: Diuretics, Restricted fluid intake <1.5L/day