CHRONIC OBSTRUCTIVE

PULMONARY DISEASE case

discussion
Moderator: DR. MALLANNA B.P
Senior consultant and HOD
Dept. of Anesthesia,D.H. Ballari.

Presenter: Dr Dhanesh
Postgraduate DNB Anesthesia
District Hospital Ballari
PATIENT PARTICULARS:

• Name: GAVISIDDAPPA
• Age :54 years
• Sex : male
• Address: Hirehaal, Bellary
• Occupation: farmer
• SES :lower class( modified kuppuswamy)
• Education:6th standard
• religion: hindu
• DOE: 20/05/2023
CHIEF COMPLAINTS:
• ℅ cough with sputum since 10year
• ℅ breathlessness since 1month
• ℅ fever since 1 week

HOPI:
• Patient was apparently 10 years back then he developed cough
with sputum, insidious in onset,slowly progressed to present
condition, present more in the early morning,no h/o seasonal
variation, aggravated by smoking,exposure to dust, deep
breathing and relieved temporarily by metered dose
inhaler,taking rest.
• cough is associated with sputum 1small tea cup in quantity per day,
earlier mucoid consistency and now purulent,foul smelling ,more in the
morning time and with smoking beedi
• H/o breathlessness since 1month, insidious in onset,gradually
progressive, earlier was getting breathlessness on hurrying on level
ground,now getting breathlessness after walking for approximately
100meters on level ground aggravated by farmwork, smoking and
relieved by
• taking rest and metered dose inhalers
• h/o multiple episodes of hospitalizations with aggravation of
breathlessness,relieved by oxygen with nebulization and iv injections. No
h/o icu admission
• h/o fever since 1 week, sudden onset , not associated with chills or rigor,
reduced temporarily by taking medication, present throughout the day
continuously if without medication, with no specific pattern
• No h/o hemoptysis, loss of appetite or significant weight loss,
no h/o hoarseness of voice,no h/o difficult in swallowing
• no h/o snoring .
• no h/o palpitation,chestpain ,orthopnoea,syncope,PND.
• No h/o evening rise of temperature,night sweats.
• No history of associated multiple episodes of sneezing,runny
nose,tearing eyes after dusting house.
• no h/o halitosis
• no h/o swelling of feet, abdominal distension, right
hypochondrial pain , puffiness of face
PAST HISTORY:
• h/o similar complaints, with hospitazations,with no icu
admissions in the past 5years , approximately 2 times in a
month, treated by oxygen with nebulization, iv injections

• No history of tuberculosis,asthma,
hypertension ,diabetes ,epilepsy, thyroid disorders.
FAMILY HISTORY:
• No history of similar complaints in family.

PERSONAL HISTORY:
• Appetite : normal
• Diet : mixed diet
• Bowel and bladder movements : regular
• Sleep : undisturbed
• history of smoking since 25 years, 1 pack(20) per day
• h/o alcohol intake of half bottle(90ml) of whisky , 2-3 days a week
since 15year
• no h/o gutka/pan/tobacco chewing
DRUG AND ALLERGIC HISTORY:
• Known history of allergy to house dust.
• treatment history:
patient is on metered dose inhaler since 5years, takes 2
puff /day,
SUMMARY:
54YR old male chronic smoker and alcoholic coming with ℅ of cough with
sputum, breathlessness, fever with h/o multiple hospitalizations in the past
with no other comorbidities on metered dose inhaler with no significant
family or allergic history.
 GENERAL PHYSICAL EXAMINATION :
• Patient is conscious , oriented to time, place and person.
• APPEARS Moderately built and nourished.
• Height-170cm ,weight- 64kg ,BMI-22.14 KG/M2

• VITALS:
• Temperature: febrile, 102’F
• PR -106bpm ,left radial artery,regular rhythm, normal volume and character,no radio
radial or no radio femoral delay,all peripheral pulses felt.
• BP-130/70 mm hg in right arm.in sitting position at rest
• RR-12cpm,abdominothoracic,no use of accessory muscles
• Spo2-96% at room air.
• JVP - Normal
• Facies- normal
• HEAD TO TOE EXAMINATION:
• No pallor,icterus,cyanosis,clubbing grade 2 present,no lymphadenopathy or pedal edema
SYSTEMIC EXAMINATION-
I.RESPIRATORY SYSTEM
A.Inspection:
• Nose-no discharge,bleeding polyp or dns
• No tenderness over maxilla or forehead
• No mouth breathing
• Good oral hygiene, no halitosis
Shape of chest-appears barrel shaped
B/L chest movements appear equal
B/L shoulders at same level
Respiration- abdominothoracic
• Accessory muscles of respiration -using
• No intercostal indrawing
• No audible wheeze or stridor
 • Skin over chest appears normal,No dilated veins, sinus or scars over chest
• No precordial or epigastric pulsations
• No deformity of spine
• Gait normal
B. PALPITATION:
• No local rise of temperature
• No tenderness
• Trachea- midline, Trail’s sign negative
• Anteroposterior diameter: 38cm , transverse diameter of chest: 43cm
AP: transverse ratio: 0.9
• Chest movements: equal on both sides
• Chest expansion: 4cm
• Vocal fremitus- equal on both sides in supraclavicular, infraclavicular,axillary,
infra axillary, suprascapular, interscapular and infrascapular areas
• No palpable rub
• Spine- no deformity, no tenderness
C. PERCUSSION:
• no tenderness over chestwall
• Resonant note heard b/l in supraclavicular, infraclavicular,axillary, infra
axillary, suprascapular, interscapular and infrascapular areas
• Cardiac dullness: 2nd to 5th ICS to left of sternum
• liver dullness: from 5th ICS on right side till just below right costal
margin , liver span 12cm
D. AUSCULTATION:
• Normal vesicular breath sounds heard in all over lung fields b/l
• wheeze is heard in right infraclavicular,infra axillary, and left infra axillary
and infrascapular areas
• coarse crepitations heard in right infraclavicular, infrascapular, left infra
axillary and interscapular areas
• Vocal resonance equal on both sides
II.CARDIOVASCULAR SYSTEM:
Inspection- chestwall appears normal
No visible pulsations or parasternal heave
Palpation- apex beat felt in left 5th ICS 0.5 inch medial to MCL, normal in
character
Auscultation- s1,s2 heard , no murmurs
III.PER ABDOMEN EXAMINATION:
A.Inspection:
Abdomen appears scaphoid, no distension
all quadrants move equally with respiration
B. Palpation: soft, relaxed
No tenderness /guarding/rigidity
No organomegaly
Organs move with respiration
C. Auscultation: bowel sounds heard, normal
No audible bruit
IV.CNS EXAMINATION:
• Pt is conscious, cooperative, oriented to time place and person
• HMF normal
• Sensory system -normal
• Motor system- normal tone and power
• reflexes -normal
• Cranial nerves -normal and intact
AIRWAY and SPINE EXAMINATION
• No facial dysmorphism
• B/l Nasal passages patent
• Mouth opening-3fingers
• Upper lip bite test-grade 2
• No retrognathia
• Teeth- normal, nobuck or loose tooth
• Tongue normal size wrt to oral cavity
• modified mallampatti - class I
• Thyromental distance: 7 cm
• Sternomental distance: 15 cm
• TMJ - no ankylosis, one finger can be insinuated
• Neck circumference: 35 cm
• neck movements: adequate
• gait- normal
• spinal column: spinous processes palpable, interspinous space normal, no deformity
E. BEDSIDE LUNG FUNCTION TESTS:
1. SABRASEZ’s breath holding time: 20 sec

2. Snider’s match blowing test

Can blow off lighted candle at 15cm

3.. Single breath count test:

Can count upto 25

4..Auscultation over trachea/steth test:

duration of expiration 6sec

• Spirometry not done

SUMMARY:
54YR old male chronic smoker and alcoholic coming with ℅ of cough with
sputum, breathlessness, fever with h/o multiple hospitalizations in the past with
no other comorbidities on metered dose inhaler with no significant family or
allergic history.

On examination,patient is febrile, tachycardia present, shape of the chest

appears barrel shaped, using accessory muscles of respiration,aP to transverse
ratio is 0.9, b/l wheeze and crepitations present. Bedside PFT showed breath
holding time of 20sec ,Can blow off lighted candle at 15cm suggesting ,single
breathing count test showed 25,on auscultation test over trachea showed
prolongation of expiration time to 6sec
 PROVISIONAL DIAGNOSIS:

• COPD probably chronic bronchitis