COPD

Subjective : Male patient , 54 years in age presents with recurring episodes of shortness of breath for the last 6 months . The patient reports that everyday normal activities result in extreme breathlessness and fatigue . He comments that a couple of years ago he was able to do the same amount of work , without any apparent fatigue or shortness of breath . He has also observes that the intensity of breathlessness has dramatically increased in the last two months . The patient also complains of a chronic cough with mucus production . The patient reports being on

medication for the last week for a chest infection . He says that there is apparent weight loss , and he has lost the appetite for food . The patient reported in the out patient department last week and was administered Amoxicillin and underwent a routine Tuberculin test which turned out negative . He also reports of a hospital admission for another episode of cough and fever nine months back . The patient is a chronic smoker , having consumed a pack of cigarettes every day for the last 30 years . The patient has been taking medications for hypertension he has no past medical history of diabetes . There is no family history of chronic diseases

Objective : General physical examination reveals that the patient is well built and athletic , weight is 220 pounds and height is 5 '11 inches . The BMI is 23 .6 . There is palor and Grade III clubbing . No signs of icterus Tongue is pale and coated . Teeth are coated black on the insides . The sputum is green in color . There is a scar on the left rib cage between the 9 and the 10th costal regions . The pulse of the patient is 90 / min The pulse is normal in intensity and volume . The respiratory rate is 25 /min and BP is 152 /110

Systemic Examination : Inspection- Breathing movements seem exaggerated on the left side of the thorax . The chest is barrel shaped and there is nasal flaring with respiration . Scapular region is prominent , and the shoulder region on the left side is drooped . The umbilicus is normal and inverted . Palpation- The chest on the left side feels warm . The trachea is shifted towards the left . The chest expands lesser on the left side compared to the right with inspiration . Tactile fremitus is asymmetric on the left side . The liver is palpated below the ribs in the right costal region . The heart is palpated between the 3rd and the 5th costal ribs on the left side and the heart beat in the left axillary plane . The liver is tender and lobular . The spleen is palpated below the left rib cage and is normal , measuring 5 cm in length and 3 cm in width . There is no abdominal tenderness or any signs of lumps in the abdominal regions Percussion- On the left side in the left scapular region there is a tympanitic note . This is also found in the left axillary line between the 7th and the 8th ribs . The right side is normal and is resonant

Auscultation-reveals the presence of coarse crackles on anterior and posterior left thoracic sides . A high-pitched wheeze is also heard with every inspiratory phase . Heartbeat is normal and symmetric

Laboratory tests done- spirometry reveals FEV1 33 , chest X ray shows diaphragm elevated on the left side , trachea shifted to the left and pulmonary hypertension . Sputum tests are positive for S .pneumoniae

Assessment : The patient has respiratory complaints , on physical examination it is seen that the patients suffers from respiratory distress on the left side of the thorax . Percussion and auscultation findings along with the diagnostic tests suggest the matching of the symptomatology with chronic bronchitis and emphysema . Coupled with the patients past history of being a chronic smoker and repeated cough and chest infections in the last years , the differential diagnosis is COPD

Plan : Preventive measures-The patient is advised to report for counseling to quit smoking . Hypnotherapy and switching to nicotine gum is recommended as an alternative . The patient is advised to take rest from work for the next month , since his daily work involves manual labor . Treatment- Bronchodilator (Inhaled Salbuterol- Combivent Mucolytic (Robitussin , Antibiotics (Amoxicillin , Oxygen Therapy Report every week for further pulmonary function testing . Patient to be advised to wear hand bracelet with emergency contact numbers

References

Sin , D . D , McAlister , F . A , Man , S . F , Anthonisen , N . R (2003 Contemporary management of chronic obstructive pulmonary disease : a scientific review . Journal of American Medical Association . 290 ,2301-12

Augusti . A . G (2005 . COPD , a multicomponent disease : implications for management . Respiratory Medicine . 99 , 670-82

Chronic Obstructive Pulmonary Disease (COPD ) Patient Case Report - PAGE 2 - ...