A 70yr old male with breathlessness and dry cough

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DR JATIN SHARMA 

Roll no. 56

A 70yr old male agriculturer brought to casualty with
C/o dry cough since 4 days
C/o breathlessness since 4 days

HOPI :
A 70 yr. Old male agriculturer  brought to casualty with complaints of dry cough since 4 days, insidious in onset, more during night then daytime, not associated with Sputum, blood tinge, chest pain. H/o seasonal variations present. Not associated with positional variation. Aggravated with fever (if present) and  cold (if present). Relieved with medication.
H/o breathlessness since 4 days, upon walking to some distance(100-200mt.) mmrc grade 2-3, gradually progressive, insidious in onset, more at night compared to day, no seasonal variation since 3 yrs. diurnal variation present, no positional variation. Aggravated on exertion, relieved at rest, orthopnea present, postural nocturnal dyspnea present since 3 yrs.

Past history :
H/o similar complaints in past started from 15yrs.
Dry cough + breathlessness was present, occasionally having seasonal (winters) + diurnal (night >day) variation since 3 yrs.
His breathlessness showed no seasonal variation.
H/o RTA 20 yrs ago, which has lead to deformity in spine ( thoracic scoliosis)
H/o similar complaints in dec, 21 2d echo showed LV hypokinesia, RWMA +, EF - 48%
K/c/o HTN since 1 yr.
No H/o Dm , asthma , TB, epilepsy

Personal history :
Appetite - normal
Diet - mixed
Sleep - normal
Bowel and bladder  movements - normal
Addictions - 1.previously occasional beer drinker, stopped 3 months ago
2. Started smoking beedi/chutta since 17yrs of age stopped 5days ago.

General examination :
Patient is conscious, coherent and cooperative, moderately built and moderately nourished.
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Pedal edema: absent
Vitals:
BP-140/90mmhg
PR- 80
RR- 37bpm
SpO2- 95% on RA in sitting position
100% on supine
GRBS-173mg/dl
Systemic Examination :
CVS- S1S2 ; no murmur heard
RS- BLAE; diffuse ronchi heard
P/A- soft non tender
CNS- HMF intact

Clinical images : 

Investigations : 

    Chest xray PA view 25-12-22

    Chest xray lateral view 25-12-22

    Usg abdomen 25-12-22

    Ecg 25-12-22 

    Abg 25-12-22

    Investigations chart 

Provisional Diagnosis ?COPD - Chronic bronchitis with old MI with Bi fascicular block with k/c/o HTN since 1 yr.

Treatment :
* Inj. Hydrocort 100mg iv stat
* NEB 2 respules duolin, budecort, mucomist every 6th hourly
* inj. Pan 40 mg iv od
* inj. Optineuron 1 amp. In 100 ml NS iv over 30min.
* o2 inhalation @ 2-4 L/min. ( target spo2 - 92%)
* inj. Hydrocort 100mg iv bd
* T.  ASPIRIN(GASTRO-RESISTANT) 75mg
   T. CLOPIDOGRIEL 75mg
   T. ATORVOSTATIN 20mg
* T. Amlong 5mg po od
* monitor vitals