Case presentation

RVS

PATIENT IDENTIFACTION
Name
: Gopalnathan A/L Velupillai
Age
: 72 years old
Sex
: Male
Race
:Indian
Ward
: Ward 25
Address :Cheras
Date of admission:7th December 2015
Date of clerking :10th December 2015

Chief complaint
Gopalnathan A/L Velupillai, 72 year old
Indian male, presented to Hospital Kuala
Lumpur on 7th December 2015, with
shortness of breath at rest since 5pm on
6th December 2015.

History of Presenting Illness

Mr.Gopal had been experiencing attacks
of breathlessness for the past 5 years and
is usually relieved by inhaler but recent
attack showed no improvement with the
inhaler. He was well until last week, when
he began to experience shortness of
breath while lying down. It started slowly, it
is getting worse, not associated with
wheezing or any sound, it is on and off.
There was no aggravating or relieving
factor for shortness of breath.

 There is no complaint of using three pillows

to sleep or awake from sleep due to
breathlessness. Patient feel tired for this
one week, however he does complaint of
loss of weight or loss of appetite. Apart
from all these, patient does not have high
grade fever, chest pain, palpitation, profuse
sweating, nausea or vomiting, bilateral leg
swelling or abdominal swelling.

 The attack also occurred with a productive

cough with copious greenish sputum.
There is no history of haemoptysis, fever,
night sweats or chest pain. Although
patient claimed that he had lost some
weight due to decrease of appetite, it was
not significant.

 Mr.Gopal is known to have history of

diabetes for the past 3 years and he was
diagnosed with Bronchial Asthma since
2008. He had no history of hypertension.
He claimed compliance to all medications.

Review of system
No significant systemic review
Past Medical History:
5 years ago he was diagnosed with
Pulmonary Tuberculosis and was treated
for 3 months after which he discontinued
medications. He also had a past history of
multiple admissions due to recurrent
asthmatic attacks.

Past Surgical History:

No history of any surgeries
Drug History:
Spiriva Acuhaler 18mg OD
T. Neulin 250 mg
T. Prednisolone 30mg OD
Formeterol Tuboinhaler 2 puffs BD
T. Augmentin 625mg stat then BD
T. Ranitidine 150mg BD
IV Maxolon 10mg
Mist expectorant 15ml
Nebulizer Combivent 6 hourly
Metered Dose Inhaler (MDI) Salbutamol
IV Hydrocortisone 100mg TDS
T. Azithromycin 500mg
T. Bisolven 8mg TDS

Con't Drug History:

IV Maxolon 10mg
Mist expectorant 15ml
Nebulizer Combivent 6 hourly
Metered Dose Inhaler (MDI) Salbutamol
IV Hydrocortisone 100mg TDS
T. Azithromycin 500mg
T. Bisolven 8mg TDS

Allergies:
No Known Drug Allergies
Social History:
He is a retired worker from the Municipal
Department, married with 5 healthy children and
currently staying with his wife. He was a chronic
smoker for 25 years and smoked 2 packets per
day (50 pack- years). He had no history of
consuming alcohol or illicit drugs.

Family History:
Both father and mother passed away due
to old age and had no history of comorbid
illnesses.

Physical Examination:
General Examination:
Patient was alert, conscious, pink and fairly
hydrated.
Signs of respiratory distress were present.
Patient was tachypnoiec and accessory muscles
were used to breathe (sternocleidomastoid,
scalene and platysma).
There was also indrawing of intercostal spaces
and inspiratory descent of trachea (Campbells
sign).

Vital signs
Temperature-37 C.
Blood pressure -196/90 mmHg.
Pulse rate -84 beats per minute, has a
regular rhythm and normal character and
volume.
Respiratory rate-22 breaths per minute.

On general examination
There was no finger clubbing, leukonychia,
koilonychia, splinter haemorrhage, flapping
tremor, cyanosis, jaundice, pallor or xanthelasma.
Corneal arcus was present.
There was no palpable lymph node or elevated
JVP.
Use of accessory muscles of respiration was
seen.

Respiratory Examination
Inspection
Patient was in respiratory distress.
Chest expansion was asymmetrical due to
decreased lung movement on the right side.
There were signs of drooping of shoulder to
the right side, hollowing of supraclavicular
fossa, infraclavicular fossa and suprascapular
fossa.
Trachea was shifted to the right side with
prominence of right sternocleidomastoid
(Trails sign).

Palpation
There was generalised decrease in vocal fremitus
and localised increase in vocal fremitus on the
upper part of the chest.
There was dullness to percussion on the upper
chest and also localised resonance was noted.

auscultation

there was decreased vocal resonance with a small area of increased vocal resonance on the upper part of the chest.
Bilateral end inspiratory crepitations and low pitched bronchial breathing were heard.
Post-tussive suction was not elicited since the patient was ill and could not co-operate much.

Ausculation
There was decreased vocal resonance
with a small area of increased vocal
resonance on the upper part of the chest.
Bilateral end inspiratory crepitations and
low pitched bronchial breathing were
heard.
Post-tussive suction was not elicited since
the patient was ill and could not cooperate much.

Cardiovascular Examination:
Cardiovascular system was clinically
normal except for the fact that heart
sounds were heard even well on
auscultation of the right axillary region.

Investigation
Full blood count
increase in wbc count
decrease in MCH values
reduce in Lym% values
Buse and creatinine
sodium and potassium levels decrease
Liver function test -normal

 Fasting serum lipid- normal

Coagulation test
increase in PT and INR
Fasting blood glucose
increase in fasting blood sugar
Blood gas
Increase in pH and pO2

Investigations
Chest x-ray
Trachea is shifted to the right side of the
lung.
There is also a prominent decrease of the
right lung volume compared to the left lung
Apical fibrosis with multiple cavities can be
seen on the right lung.
There is tenting of the diaphragm on the
right side. Costophrenic angle is sharp
which is normal.