Summary 3

My patient is Mr, SK, 63 years old gentleman, with underlying chronic obstructive pulmonary disease for the past 4 years, uncontrolled hypertension for the past 4 years as well, persistent atrial fibrillation for 2 years and previous smoker for 20 pack years presented with shortness of breath and productive cough for the past 2 days. The shortness of breath and cough started when he exerted himself while walking a distance of 50m. He took 4 puffs of MDI Salbutamol but did not relieve his symptoms.

Question: What do you infer when you hear that "He took 4 puffs of MDI Salbutamol but did not relieve his symptoms."?

Prior to that, he exerted himself while performing daily chores. His cough was minimal in amount, no hemoptysis or foul smelling sputum. Besides that, he has no fever, sore throat, runny nose, orthopnea, paroxysmal nocturnal dyspnea or bilateral leg swelling. This is his fourth admission, this year for the similar problem and was previously diagnosed with Acute exacerbation of COPD secondary to URTI. Three years ago, he was given SR Theophylline but developed A.fibrillation after 1 year.

Question: What does the onset of atrial fibrillation imply?

He is currently treated with MDI Berodual, TDS, MDI Budesonide, BD, MDI Salbutamol, PRN. Also, he is on T. Verapamil,80 mg, TDS, T. Digoxin, 0.125mg, OD and T. Ticlopidine, 250mg, OD.

Question: Why is he on Verapamil? Why is he on Digoxin? Why is he on Ticlopidine?

As for physical examination, he was afebrile, blood pressure was elevated 165/95 mmHg, pulse rate 86 beats, irregularly irregular and respiratory rate tachypneic, 24 breaths per minute and Spo2 was 98% under room air. His lung findings were reduced chest expansion, hyper-resonant on percussion, reduced tactile and vocal fremitus bilaterally and prolonged expiratory phase with occasionally rhonchi both sides. He has no raised JVP, tender hepatomegaly or bilateral pitting edema. Normal S1 and S2 heart sounds were heard with no loud P2 or S3 gallop.

As for his management, he was given nebuliser AVN, 4 hourly followed by 6 hours and kept under 3L of Nasal Prong. Full blood count, renal profile, liver function test, lipid profile and coagulation profile was normal. ABG showed compensated respiratory acidosis with oxygen saturation of 84%.

Question: Why did his SpO2 reduce from 98% to 84% after bronchodilators and oxygen? What is the significance of what you describe as "compensated respiratory acidosis"?

His chest X-ray showed Hyperinflated lungs, flattened diaphragm and tear drop heart. He was given T.Prednisolone, 40mg for 5 days and T.Bisolven, 8mg, TDs. He was discharged with MDI Berodual, MDI Budesonide, MDI Salbutamol, and Tablet Prednisolone, 40mg for 3/7.

Question: What is the reason for giving Bisolvent?

Final diagnosis: Acute Exacerbation of COPD secondary to Non infective cause with underlying long persistent atrial fibrillation, uncontrolled hypertension and previous smoker for 20 pack years.

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