Summary 12

Mr SSD, 80 year old Malay man, chronic smoker of 45 pack years with known diabetes mellitus, hypertension and chronic obstructive pulmonary disease (COPD) complained of sudden onset of shortness of breath one day prior to admission.

Question: What differential diagnoses will this history of SOB suggest to you?

It was aggravated by physical exertion and was not relieved by inhaler. He had productive cough with whitish sputum and intermittent fever for the past two weeks. There was no hemoptysis or loss of weight.

Question: What is the significance of "hemoptysis and loss of weight" in this person?

He did not have paroxysmal nocturnal dyspnea or orthopnea. Patient had an episode of hospital admission due to acute exacerbation of COPD 2 years ago. The COPD was well controlled after being discharged and there was no attack for the past 2 years. There no was history of intubation or ICU admission. He is compliant to the treatment.

On examination, patient was conscious, alert and responsive. He was not in pain or respiratory distress. He was on nasal prong 3L/min with SpO2 of 98%. His vital signs: temperature 36.7°c; Blood pressure 118/68mmHg; Pulse rate 80 beats per minute; Respiratory rate: 22 breaths per minute. On respiratory examination, the air entry was equal and vesicular breath sounds could be heard. There were generalized rhonchi with bilateral basal fine crepitation. Other examinations were normal.

Question: What will you consider as the cause of the basal crepitations?

Full blood count revealed leukocytosis (WBC: 11.5 x 109/L)). ABG on admission showed Type 1 respiratory failure with compensated metabolic acidosis. ESR was raised. Chest X-ray showed hyperinflation of the lung and perihilar haziness bilaterally. No cardiomegaly noted. Gram negative cocci were found in the sputum culture and sensitivity. Peak flow rate was done and showed that there was variability in the peak expiratory flow rate after nebulization. Renal profile showed raised urea (8.5mmol/L) and creatinine (162umol/L)

Question: Explain how this person has developed "Type 1 respiratory failure with compensated metabolic acidosis". What does the "perihilar haziness" on the chest x-ray represent? What organism do you think is the cause of the " Gram negative cocci found in the sputum culture and sensitivity"?

Patient was diagnosed acute exacerbation of chronic obstructive pulmonary disease secondary to community acquired pneumonia with diabetes, hypertension and stage 3 chronic kidney disease.

Question: Why do you say that his elevated serum creatinine is because of chronic kidney disease?

He responded well to nebulization with Ipratropium bromide and Fenoterol, T. prednisolone 30mg and MDI berodual (Ipratropium bromide 20mcg, feneterol 50mcg) 2 puff TDS. He was also treated with IV Augmentin 1.2g TDS and T. azithromycin 500mg OD. He was referred for chest physiotherapy. A pharmacist had counseled and reviewed his inhaler technique. Patient was discharged on the day 4 of admission as the symptoms had resolved. He was discharged with MDI Berodual, T. Prednisolone 30mg OD and T. Augmentin 625mg BD for three days. He will continue his follow up after 3 days at Klinik Kesihatan Lukut for the review of symptoms and renal function.

Question: What important information about this patient is missing in this summary?

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