CASE PRESENTATION PULMUNOLOGY DEPARTMENT

ANAMNESIS
NAME : Lee Choon Lye AGE : 77 years old SEX : Male RELIGIOUS : Buddha OCCUPATION : Ex policeman ADDRESS : No 8 pekan pauh, Arau DOA : 20/11/2011 TOA : 5.35 pm

CHIEF COMPLAINT
SOB - 2/7

ADDITIONAL COMPLAINT
Fever 4/7 Cough on and off

HOPI
Pt is K/C/O COPD and PTB diagnosed a month ago and discharged from ward on 24/10/2011.Worsening of SOB since 2 days ago prior to admission. Pt have difficulty to breath all the time and have to be in prop out position.Unfortunately, his condition worsened and pt was brought to the casualty. Pt also noted to have productive cough coming on and off since discharged a month ago.Sputum described as whitish colour and in small amount. Patient also having fluctuating fever since 4 days ago.No temperature recorded prior to admission and patient was given paracetamol but not completely resolved.According to his family,pts consciousness started to deteriorate within this week.Patient also presented with tachypnea.Pts family also reported that he is bedridden and cant tolerate orally since he was discharged. Otherwise there is no chest pain and no hemoptysis.

 Past medical Hx - diagnosed TB a month ago Drugs Hx - TB drugs Allergies - not allergic to any foods or drugs Family Hx - not significant Social Hx - heavy smoker since young - no hx of contact with tb person - after pension works as farmer

GENERAL SURVEY
Sensorium : stupor, not alert but response to call Blood pressure : 139/84mmHg Pulse : 135x/min Respiratory Rate : 22x/min Cyanosis : pallor at both extremities Icteric : no sign Hydration : no sign Oedem : no sing Nosed-breathing : no sign Distress : no sign Weight : 48 kg Height : 167 cm

PHYSICAL EXAM
Pt look very ill and not very cooperative with the physical examination Eyes : anemic and no icteric On venturi mask with ventilation support Tracheal deviation to the right side Nicotine stains at right hand and no clubbing finger No sign of oedema (pre tibial,ascites)

PD (anterior)
Inspection
abdominal-thoracal, symmetris and fusiform in shape, usage of accessory muscles, no scar, no venectation, no chest lag.

Palpation
cant be done due to pts condition

Percussion
dullness

Auscultation
breath sound : prolong expiration additional sound : generalized ronchi bilaterally : crept at left upper zone

Full Blood Count

Value White Blood Cell Red Blood Cell Hb Ht MCH MCHb MCHC Platelet 20.9 3.8 10.7 34.5 90.8 28.2 31 196 Unit 10^9/L 10^6/uL g/dL % fL pg g/dL 10^3/uL Low High Low Low Low

Arterial Blood Gas

Arterial Blood Gas pH PCO2 PO2 HCO3act HCO3std BE 02 Sat ctCO2 Date : 20/11/2011 Value 7.463 27.1 62.3 19.1 21.6 -3.2 90.3 17.4 mmHg mmHg mmol/L mmol/L mmol/L % mmol/L Unit Normal 7.35-7.45 35-45 80-100 22-26 22-26 +2 - -2 96-98 22-26

Renal Profile
Renal Profile Sodium Potassium Urea Creatinine Calcium Phosphate Value 130 4.9 6.8 112 2.11 1.46 Unit mmol/L mmol/L mmol/L umol/L mmol/L mmol/L Normal Range 135-145 3.3-5.3 1.7-8.3 <115 (age<50) <124 (age>50) 2.15-2.55(adult) 0.87-1.45(adult) 1.6-3.1(neonates)

Date: 20/11/2011

Liver Function Test

Liver Function Test Total Protein Albumin Globulin A/G Ratio Total Bilirubin Direct Bilirubin Indirect Bilirubin ALP ALT Value 74 22 52 0.4 27 12 15 65 41 umol/L umol/L umol/L U/L U/L 0-24 2-5 2-12 40-129 0-41 Unit g/L g/L g/L Normal Range 66-87 34-48 28-36

Cardiac Enzymes
Cardiac Enzymes CK LDH AST CK-MB Magnesium Value 504 1312 112 49 0.93 Unit U/L U/L U/L U/L mmol/L Normal Range <170 240-480 0-38 0-24 0.7-1.2

CHEST X-RAY

ECG

DIFFENTIAL DIAGNOSIS
Pneumonia COPD Bronchiectasis *To rule out ACS

WORKING DIAGNOSIS
AECOPD secondary to Pneumonia with underlying PTB

TREATMENT & PLAN

BP and sp02 monitoring Antibiotic- Combination therapy usually consists of ceftriaxone plus doxycycline, azithromycin, or quinolone.
In this case,pt was given IV Azithromycin 500mg

Nebulized B2-agonist Assisted ventilation-High flow mask 10L/min Continue TB treatment

THANK YOU