CME CASE PRESENTATION

MUGUME DENIS
MbCHB V
 PATIENT’S BIO DATA
• Name: K.P
• Age : 47 years
• Sex: female
• Address :Kyabukonkoni village, Rwengoma
parish, Central division, Fort portal city.
• Tribe : Mutooro
• Religion : Anglican
• Marital status : widowed
• Occupation : Peasant
• Highest level of education : Senior two
• Nearest health facility : FPRRH(transport cost
is 3000 shillings on a boda boda)
• Referral status : From home
• Next of kin : KW-patient’s son
• Date of admission : 13th June 2024
• Date of discharge : 22nd June 2024
 PRESENTING COMPLAINT
• Difficulty in breathing for 1 month.
• Headache for 1 month.
 History of presenting complaint.
• A 47 year old known ISS for 27 years on TLD
with unknown adherence,CD4 count and viral
load; known hypertensive patient for 10 years
with poor adherence due to severe drug side
effects; and a chronic smoker for 24 years with
13.5 pack years reported with a one month
history of difficulty in breathing and headache.
• The difficulty in breathing was present throughout
the day , but worsened by any physical activity. The
patient described the headache as intense with a
score of 7/10,throbbing and would also worsen on
any physical activity.
• The above symptoms were associated with chest
pain , productive cough with whitish sputum
production , wheezing and easy fatigability and
several episodes of generalized tonic clonic
convulsions.
• However , there was no associated night
sweats ,marked weight loss , loss of appetite,
lower limb swelling , paroxysmal nocturnal
dyspnea , orthopnea , palpitations , or
photophobia.
• The patient also reported that she had been
cooking using firewood for very many years.
 Review of other systems
Gastrointestinal tract system
• There was no history of vomiting , passing out
loose stools , abdominal pain , abdominal
distension or constipation.
Genitourinary tract system.
• The patient reported normal urine colour ; no
painful urination , frequency, urgency ,
incomplete urination or incontinence
Ear nose and throat system
• There was no hstory of ear pain , discharge or
bleeding.
Musculoskeletal system
• There was no history of joint pain , swelling or
difficulty in movement.
 Past medical history
• The patient is a known ISS patient on TLD , a known
hypertensive patient who was not on drugs at the time of
admission due to severe headache associated with taking
antihypertensive drugs. She however has no diabetes mellitus,
asthma, sickle cell disease or any other chronic medical illness.
• The patient reported that this current admission was the third
time of being admitted in this year for the same symptoms;the
first time was in February when she was first diagnosed with
COPD, managed and discharged with improvement and the
second time was in May this year when she was admitted , still
diagnosed with COPD, managed and discharged with
improvement.
• The patient reported no history of drug
allergies or food allergies.
 Past surgical history
• The patient reported no history of road traffic
accidents, blood transfusion, major surgeries
or any trauma.
 Family-social history
• She has three children two boys and one girl, but
all of them no longer stay with her.
• She sleeps under a mosquito net, boils her water
for drinking and had been smoking both cigarettes
and marijuana until February this year when she
was advised to stop after being diagnosed with
COPD at FPRRH.
• She reported a familial history of hypertension in a
paternal aunt, but no any other history of familial
illnesses.
 Summary
• A 47 year old female known ISS on TLD, known
hypertensive not on medication at time of
admission and chronic smoker with 13.5 pack-
years presented with one month history of
difficulty in breathing and headache. These were
associated with productive cough, chest pain,
wheezing, easy fatigability and convulsions. No
history of loss of appetite, night sweats, weight
loss, lower limb swelling, paroxysmal nocturnal
dyspnea, orthopnea ,palpitations or photophobia.
 Physical examination
General examination.
• A middle aged female alert and
conscious ,looking to be in good nutrition state,
but in obvious respiratory distress, seated in her
bed in a tripod position.
• She is afebrile, no cyanosis, pallor, jaundice
digital clubbing, lymphadenopathies or edema.
• Vital signs:BP-154/122 mmHg, pulse rate-111
bpm,SPO2-95% at RA,RR-29 cpm,temp-35.7.
 Respiratory examination
On inspection;
• The chest was of normal shape and size, moving
with respiration, no surgical scars or therapeutic
scars and the patient was seated in a tripod
position.
On palpation;
• The trachea was centrally located, there was
bilaterally equal chest expansion on right and
left side, but there was reduced tactile fremitus.
On auscultation
• There was reduced air entry bilaterally,
audible wheezes on both sides, and fine
crackles in all the auscultatory areas of the
chest.
On percussion
• There was a normal reasonant percussion
note in all the areas of the chest.
 Cardiovascular examination
• There were no ossler nodes, janeway lesions.
• The radial pulse was present and of normal full
volume, synchronous and of normal rhythm.
• BP was 154/122 mmHg and PR was 111 bpm.
• Jugular venous pressure was not raised, and carotid
bruit was absent.
• The precordium was normoactive, heart sounds S1 and
S2 were heard, no added sounds and the apex beat
was in the 5th intercostal space on the left chest side
along midclavicular line.
 Abdominal examination
• The abdomen is of normal fullness moving on
respiration, umblicus in inverted, no
paraumblical vessels visible, no obvious masses
and no surgical or therapeutic scars.
• The abdomen is nontender, no organomegalies
and no other palpable masses.
• There is tympanic percussion note in all the
areas of the abdomen. No fluid thrill or shifting
dullness.
 Central nervous system examination
• The patient was alert and conscious. The GCS
was 15/15.the neck was soft, speech was
normal and memory was normal with intact
cranial nerves.
• There was normal muscle bulk, tone, power
and reflexes in both upper and lower limbs.
 Diagnosis
• A 47 year old female known ISS and known
hypertensive with acute exacerbation of
COPD.
 Treatment
At A & E
• She was nwbulised two times with 2.5mls of
duolin and was later sent to ward.
On ward
• Nebulized with salbutamol 5mg 4 hourly
• IV hydrocortisone 200mg 6 hourly
• Famonide inhaler 2 puffs 4 hourly
• Tabs azithromycin 500mg BD
• Tabs predisolone 30mg OD
• IV levofloxacillin 500mg OD
• Ascoril syrup 10mls TDS
• Lorsatan 50mg OD
• Continued ART.
 Investigations
While on ward the following investigations were
carried out.
• Chest X-ray which revealed hyperlucence of
both lungs.
• Serum Crag which was negative
• CD4 count which revealed 184 cells/ microL
• LFTs and RFTs which were all normal.
 Discharge instructions
After 9 days of stay on ward, the patient was
discharged while stable on the following medications.
• Tabs Azithromycin 500mg OD × 5/7
• Famonide inhaler 2 puffs 4 hourly
• Ascoril syrup 10mls TDS
• Tabs predisolone 30mg OD × 2/52
• Tabs Lorsatan 50mg OD × 1/13
• Continued on HAART
• To come back for review after 2 weeks.