My patient , ABC , 53 years old, Male, Supervisor at construction site by

occupation , resident of Tardeo , Mumbai hailing from Faridabad ,Haryana, came

with the chief complaints of

Exacerbation of Breathlessness ,since 4 days

Exacerbation of Cough with expectoration,since 4 days.

HISTORY OF PRESENTING ILLNESS:

The patient complains of breathlessness from last 10 to 15 years which has

worsened from last 4 days, insidious in onset and gradually progressive and with
seasonal variation.

Initially patient noticed that he walks slower than his colleagues of same age and
has to stop for a breath while walking and he was able to perform his daily
activities at workplace.
But now he is breathless while doing routine activities not able to go for work.
(i.e. MMRC grade 2 to4 )
breathlessness is present intermittently throughout the day and There is NO
positional variation.

The breathlessness was associated with cough with

scanty amount of sputum which is
white in colour ,mucoid consistency
not blood tinged ,not foul smelling.

initially, cough and expectoration was present only in the winter season more in
the morning with no positional variation ,later it became consistent.

His symptoms gradually progressed so that even in between the attacks or

episodes of worsening he could do only less than moderate work and during the
episodes of worsening he was symptomatic even at rest preventing him to do his
activity of daily living.
For the last few years he had more aggravation of symptoms requiring few
hospitalisation for the relief.
NEGATIVE HISTORY:
Chest Pain
NO h/o: Fever
Palpitations (MAT)
Copious Foul smelling sputum ( Brochiectasis)
Dry Cough ( ILD)
Orthopnoea, PND
Pedal edema, Abdominal distension
hemoptysis,weight loss (bronchogenic Ca)
Dysphagia or hoarness(laryngeal/mediastinal mass)
Aspiration of food/foreign body
TB contact/low grade fever with evening rise a/w cough ,unintentional
weight loss,night sweats
Rhinitis, sinusitis, Conjuctivitis
Joint pain, Skin rashes ( CTD)
Eczema/skin lesion (Atopy) Asthma

PAST HISTORY:
Similar complaints of breathlessness since 10 years for which has admitted to the
hospital around 8-9 times and treated ,previous episodes were comparatively less
severe than the present episode
Pt. was advised to use inhalers as a medication but Non-compliant.
Not a known case of hypertension,diabetes, asthma ,heart diseases
NO known allergies
NO history of prior surgery
FAMILY HISTORY:
No history of similar complaints in the family
No history of asthma

PERSONAL HISTORY :
Patient is Chronic smoker since past 25 years
CPD: 4
Smoking index: 100
Additionally,
Environmental tobacco smoke (ETS) :secondhand smoke exposure in the
workplace.

No h/o alcohol intake or substance abuse

Sleep is disturbed.
Appetite: Mixed diet
Bowel & Bladder : No complaints
OCCUPATIONAL HISTORY:

Patient has worked in glass manufacturing industry In Faridabad for 10 years

Later he worked as supervisor in various industries for 10 yrs in Delhi NCR
which could have exposure to toxic vapours ,gases,mineral dust, fumes
(VGDF).
Air pollution in Delhi NCR was likely an additive factor.

SUMMARY :/PROVISIONAL

My patient ABC, 53 y/o , Who is a chronic smoker gives a history of

breathlessness associated with cough scanty mucoid expectoration for almost
10 yrs with h/o of repeated hospitalisation for intermittent exacerbations, has
now come with acute exacerbation of symptoms (MMRC grade 4 ) from 5 days.
Most likely a case of Acute Exacerbation of Chronic Obstructive Pathology, .
1. Chronic Bronchitis/ Emphysema
2.Occupational lung diseases / ILD/ Pleural thickening
3. ACOS: Asthma COPD overlapping Syndrome.

GENERAL PHYSICAL EXAMINATION:

Patient is examined in well lit room with adequate exposure

sitting on Stool and with due consent
Patient is conscious ,well oriented to time , place and person
Average built, well nourished.
Pt. appears distressed

the patient is in sitting and leaning forward posture with outstretched

hands on knees (Tripod position)

Pursed lip breathing

BMI : 21.5 Kg/sq.mtr

Afebrile to touch

Pulse :78 beats per minute in right radial artery in sitting position with
adequate force,volume and tension with no radio- radial or radio-femoral
delay . All peripheral pulses felt

BP : 124/78 millimeters of mercury in Right brachial artery in sitting

position
 RR : 26 per min regular ,abdominothoracic ,shallow respiration

JVP: Not raised. (Cor pulmonale)

Hepatojugular reflex +/?

Pallor Absent
Icterus Absent
Cyanosis Absent. (Chronic bronchitis/ NOT blue bloater)
Clubbing Absent
Gen. lymphadenopathy Absent
Pedal Edema Absent. (RV failure cor pulmonale)
stigmata of TB absent
No features of Marfanoid habitus
spine : normal.

Systemic Examination:

Upper respiratory tract:

Oral cavity: Nicotine staining present on teeth

Nasal cavity :Normal
No polyp/septal deviation. (WG)
No sinus tenderness
Post. Pharyngeal wall : Normal

INSPECTION:

expiration prolonged through Pursed lips.

No tracheal deviation
Apex beat : Not visible

Chest wall:
Shape and symmetry: Barrel shaped chest (A-P diameter: Transverse diameter = 1:1)
Bilaterally symmetrical

Ribs are places more widely& horizontally ( intercostal spaces are increased)
Accessory muscles of respiration used
no dilated veins, pulsations, scars or sinuses
no spinal deformity (kyphoscoliosis)
no drooping of shoulder
HOOVERS SIGN: +ve

Respiratory Movements: Decreased movement Bilaterally and symmetrically over

all areas.
Region RIGHT chest movement LEFT
Supraclavicular Decreased Decreased
Infraclavicular Decreased Decreased
Mammary Decreased Decreased
Axillary Decreased Decreased
Infraxillary Decreased Decreased
Suprascapular Decreased Decreased
Interscapular Decreased Decreased
Infrascapular Decreased Decreased

PALPATION:
Inspectory findings confirmed
No local rise in temperature or tenderness

During Inspiration: Campbell sign +ve (downward displacement of trachea )

No tracheal deviation
Apex beat: left 5th ICS medial to MCL / NOT felt?

Measurements :AP diameter 30 cm

transverse diameter :32 cm (ratio- 0.93)
chest circumference :on expiration 98 cm
on deep inspiration 101 cm
chest expansion 3 cm ( reduced)
TVF: Decreased on both sides

Chest Expansion: Decreased Bilaterally and symmetrically over all

areas.

Region RIGHT LEFT

Supraclavicular Decreased Decreased
Infraclavicular Decreased Decreased
Mammary Decreased Decreased
Axillary Decreased Decreased
Infraxillary Decreased Decreased
Suprascapular Decreased Decreased
Interscapular Decreased Decreased
Infrascapular Decreased Decreased
PERCUSSION:

Region RIGHT chest percussion note LEFT chest percussion note

Supraclavicular Hyper-resonant Hyper-resonant
(Kronig’s isthmus)
Clavicular percussion Hyper-resonant Hyper-resonant
Infraclavicular Hyper-resonant Hyper-resonant
Mammary Hyper-resonant Hyper-resonant
Axillary Hyper-resonant Hyper-resonant
Infraxillary Hyper-resonant Hyper-resonant
Suprascapular Hyper-resonant Hyper-resonant
Interscapular Hyper-resonant Hyper-resonant
Infrascapular Hyper-resonant Hyper-resonant

Liver dullness: pushed down 6th ICS

Cardiac dullness : present/ Reduced

ASCULTATION:

Breath sounds: Markedly Diminished vesicular breath sounds on prolonged

expiration bilaterally and symmetrically over all areas.
With expiratory polyphonic Wheeze. (r/o ILD)
(Monophonic in Asthma)

Region RIGHT LEFT

Supraclavicular Decreased Decreased
Infraclavicular Decreased Decreased
Mammary Decreased Decreased
Axillary Decreased Decreased
Infraxillary Decreased Decreased
Suprascapular Decreased Decreased
Interscapular Decreased Decreased
Infrascapular Decreased Decreased

VOCAL RESONANCE: Decreased Bilaterally and symmetrically over all areas.

Other system examination:

CVS : Muffled heart sounds, S1,S2 heard

No murmus heard

P/A : Non tender

Liver,spleen not palpable

CNS : Higher mental functions normal No sensory or motor deficit

DIAGNOSIS:

My patient ABC, 53 y/o , having progressive breathlessness associated with

cough scanty mucoid expectoration
Most likely a case of Acute Exacerbation of Chronic Obstructive lung
disease with Emphysematous variant without any complications
Secondary to chronic active & passive Smoking, occupational exposure of
VGDF.