Smoking, an ultimate cause for Chronic Obstructive Pulmonary Disease

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 centered online learning portfolio.

CHIEF COMPAINT:

A 62 year old male who is a farmer by occupation came to OPD with the chief complaint of:

-shortness of breath since 3 months

-cough with sputum since 3 days

-fever occasionally (on&off)

HOPI:

Patient was apparently asymptomatic 1 year back, then he developed shortness of breath for which he was taken to private hospital and was Rx with nebulization and oxygen and was relieved. Patient was asymptomatic 6 weeks.

Then he developed fever (on&off) associated with climate change.

The SOB was insidious in onset, slowly progressive associated with cough and cold also with seasonal variation.

Daily Routine: Patient used to wake up at 7 am. He used to take chapatti in his breakfast and then go for work and return home till 8pm. occasionally he used to drink at night before sleeping. he used to have rice for lunch and dinner.

PAST HISTORY:

N/K/C/O Diabetes Mellitus, hypertension, asthma, CAD, CVA, tuberculosis and epilepsy.

No H/O chest pain, palpitations and pedal edema.

No H/O orthopnea and paroxysmal nocturnal dyspnea.

FAMILY HISTORY:

There is no similar complaints in his family.

PERSONAL HISTORY: 

Married 

Occupation: Farmer

Diet: mixed

Appetite: normal

Bowel and bladder movements: regular

Micturition: normal 

Socio- economic: poor

Sleep- adequate

Habits - Alcohol- occasional 

               Tobacco- 40packs/year

GENERAL EXAMINATION:

The patient is examined in well light room. He is conscious, coherent and cooperative and well oriented to time, place and person and consent was taken to examine him.

Pallor - Absent

Icterus -Absent 

Cyanosis - +

Clubbing - +

Lymphadenopathy -Absent 

Pedal Edema - +

Dehydration: absent

VITALS:

Temp: 98.6°F

B.P: 130/80 mm Hg

PR: 82 bpm

RR: 20 cycles / minute

GRBS: 110mg%

SPO2: 99%

SYSTEMIC EXAMINATION:

CVS:

S1 and S2 sounds +

JVP raised

Pansystolic murmurs +

RS:

Dyspnea - absent

Wheeze- polyphonic wheeze 

position of trachea- central

Breathing pattern- abdominal 

Abdomen:

Distended shaped abdomen, 

non tender & no organomegaly detected

CNS:

Conscious and normal speech

normal gait

cranial nerves are intact

sensory system is normal

motor system is normal

reflexes are normal

INVESTIGATIONS:

USG:

USG IMPRESSION: RAISED ECHOGENICITY OF BILATERAL KIDNEYS

INCREASED GALL BLADDER WALL THICKNESS

BILATERAL SIMPLE RENAL CIRTICAL TRIANGLE

Chest X Ray :

2D ECHO:

ECG:

PROVISIONAL DIAGNOSIS:

Acute exacerbation COPD (Bronchitis>Emphysema) with heart failure.

TREATMENT PLAN:

1. Neb Ipravent 2 resp TID

2. Neb Budecort 2resp BD

3. Tab deriphyllin 100mg PO/ BD

4. Tab lasix 40mg PO/BD

5. Tab telma 20mg PO/OD

6. Syrup ascoryl-LS 100ml PO/TID

7. Monitoring BP /PR /RR /SPO2 -4th hourly.