62 years old female with Chronic cough and Hemoptysis

Dr.ABDUL RAHEEM (INTERN)

Dr.ASHFAQ (INTERN)

Dr.GNANADHA (INTERN)

Dr.SRAVYA (INTERN)

Dr.CHETANA (INTERN)

Dr.NAVYA (INTERN)

Dr.VAMSHI ( PG1)

Dr.SAI CHARAN(PG1)

Dr.SUSMITHA (PG2)

Dr.ADITYA (PG3)

Dr.PRANEETH(PG3)

Dr.PRAVEEN NAIK (ASS.PROF)( duty on call 1)

Dr.RAKESH BISWAS (PROF.AND HOD) ( duty on call 2)

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Here is a case i have seen:

A 62 year old female came to OPD chief complaints of cough with expectoration and SOB since one month.fever since one month.vomitings and loose stools since 4 days

HOPI:

 patient was apparently asymptomatic 20 years back later she had intermittent cough ( once in a month )which is relieved on taking medication but one month ago she had fever which was high grade with chills associated with low backache and SOB associated with cough with expectoration which was insidious in onset for this she went to hospital where she diagnosed with anaemia managed conservatively and she is on ceftriaxone. Symptoms aggravated more since 4 days , blood in sputum and wheeze present.

  H/o vomitings since 4 days which are 4-6 episodes/ day,food and water as content,non bile stained, non blood stained.

H/o loose stools since 4 days 5-6 episodes/day.

H/o loss of appetite present.

Significant weight loss present

No h/o burning micturition,melaena, headache.

Past history-

No history of hyperhypertension, diabetes mellitus, epilepsy,thyroid disorders, asthma, tuberculosis.

No past surgical history and blood transfusions.

Family history-

 - Her brother  had similar complaints, died 25 years ago.

 - Her sister has similar complaints chronic cough and SOB takes inhalers.

Menstrual and marital history-

Attained menarche 13 years of age and married at 14 years.

Menstrual cycles are regular 4/30, 

Attained menopause by 45 years of age.

No known drug and allergies.

General examination-

PT is conscious, orientated to time, place, person, cooperative.

Thin built and  Malnourished.

Skin fold thickness : 4mm.

HT-158 cm

Wt- 33 kg

BMI-13.25

PALLOR +, koilonychia +, clubbing +( fluctuation +),

No signs of icterus,cyanosis,  generalised lymphadenopathy,paedal edema.

Vitals-

Temperature-99.3F

PR- 105 Bpm

RR- 28 cpm

Bp- 100/60 mm of Hg

Head to toe Examination:

Temporal wasting present.

Shiny, bald  ,bulky, red tongue.

Greyish white patch is seen over soft palate.

Muscle wasting present: temporalis, deltoid.

Ichthyotic skin present on upper limbs and lower limbs.

?hard, mobile,2.5cm left supraclavicular lymph node present.

Lower thoracic and lumbar kyphoscoliosis present.

Lower limb : significant muscle wasting present.

Saddle nose deformity +

Respiratory examination:

Inspection-

Oral cavity- poor oral hygiene 
UR-:12- 45678. UL:12345678.
LR:123--- 78. LL :12---- 78.
Cervical Trachea appears to be central.
Trail’s sign+. 

Drooping of shoulder , on left side
Broadbent’s sign +:systolic retraction in 3rd and 4th ICS.

Kyphosis seen with medial border prominence of Scapula
Dilated veins seen  over neck, right upper anterior aspect and left hemithorax.

Barrel shaped chest.

Suprasternal pulsations present
visible pulsations present in left mid clavicular line below the nipple( 4cm).
Epigastric pulsations +.
Posteriorly left side lower thoracic region - ?aortic  pulsations present.
Abdominothoracic type respiration

Resp. movements    Right.             Left.

Upper zone                   ✓.           Decreased

middle  zone                ✓.            Decreased

Lower zone                   ✓.           ✓

Accessory muscle usage present.

1.SCM

2.Scalenus

Palpation- 
Trachea- Mediastinal tracheal shift to right
no local rise of Temperature and tenderness.
Left side over crowding of ribs +.
Apex beat felt over left to left mid axillary line in 5th intercostal space (4cm).
Anteroposterior diameter(APD)- 24 cm.
Transfers diameter(TD)-24cm.(APD/TD: 1/1).

Resp. Movements.       Right.        Left.

Anterior:

Upper zone.                     N.       Decreased

middle zone                    N.        Decreased

Lower zone                      N.       Decreased

Posterior:

Suprascapular.               N.         Decreased

Interscapular.                  N.        Decreased

Infrascapular.                  N.        Decreased

Percussion-

Direct : resonant over clavicular, sternum.

Indirect :

Anterior.                  Right.               Left.

Supraclavicular.     Resonant.        Dull    

Infraclavicular.       Resonant.        Flat

Supra mammary    Resonant.        Falt

Mammary.               Resonant.       Flat

Inframammary.       Dull.                 Flat

Axillary.                    Resonant.       Dull

Infraaxillary.            Dull.                 Dull

Posterior:.                    Right.           Left.

Suprascapular.        Resonant.         Dull

Interscapular.          Resonant      stony dull

Infrascapular.          Resonant.         Flat

Auscultation- decreased air entry in both the lung areas. bilateral coarse Crepitations heard in both the lung areas.

Aegophony and bronchophony in 

                                  Right.                  Left

Supraclavicular.           ✓      tubulobronchi.

Infraclavicular.            ✓     tubulobronchi

Supra mammary    A&B.      tubulobronchi

Mammary.              A&B       tubulobronchi

Inframammary.           ✓.     tubulobronchi

Axillary.                       ✓                   ✓

Infraaxillary.             ✓.                     ✓

Suprascapular.         ✓.        Tubulobronchi

Interscapular.           ✓.        Tubulobronchi

Infrascapular.            ✓.        Tubulobronchi

Per abdomen- 

Distended abdomen, everted umbilicus present. Distended abdominal veins.

Shifting dullness present.mild spleenomegaly.

Bowel sounds heard.

? Portal hypertension
 

CVS- S1,S2 heard.

CNS- No focal neuronal deficits

 Reflex's                 Right.             Left.

Jaw jerk.                 +.                    +

Schimizu                +.                   +

Biceps.                     +++.               +++

Triceps.                    +++.               +++

Supinator.                 +++.               +++

Finger flexor.            +++.               +++

Knee.                         +++.               +++

Ankle.                        +++.               +++

Plantar.                      +++.               +++

Investigations-

ABG- 

PH- 7.24

PCO2- 32 mm hg

Po2- 79.3 mm hg

Hco3- 13.2 mmol/L

2D - Echo

Moderate Tricuspid Regurgitation(TR) + with Pulmonary artery hypertension
Mild  Mitral Regurgitation+/Aortic Regurgitation+.
Left Anterior Descending hypokinesia, Right Coronary Artery Left circumflex hypokinetic ,no Aortic Stenosis /Mitral Stenosis.
Moderate Left Ventricular dysfunction+
Diastolic dysfunction +, No Pulmonary Embolism.
USG-
B/L grade 1 Renal Parenchymal Disease changes present.

BT- 2 Min

CT- 4 Min

PR- 15

INR- 1.11

APTT- 30

Hb- 13.4 

Anti HCV- Negative

HBsAg-negative

HIV1/2- negative

DENGUE- negative

 Chest X ray-

Lung collapse on both sides with possible Cavitary lesion in Rt upper lobe

Lower mediastinal shift on right side with inwardly pulled Rt Costophrenic angle.

Treatment given-

Tab. PCM 650 mg stat

Neb. With IPRAVENT 4th hourly.

Head end elevation.

On day 2

RFT-

Urea-145 mg/dl

Creatinine-1.9 mg/dl

Uric  acid-10.4 mg/dl

Calcium-8.6 mg/dl

Phosphorus-3.4 mg/dl

Sodium-136 mEq/l

Potassium-4.1 mEq /l

Chloride- 102 mEq/L

HRCT- thorax plain

Sputum1. AFB-

               2. CBNAAT-

LUNG BIOPSY- done for mass in left upper lobe ( 4 th ICS).

Post biopsy x-ray

BRONCHOSCOPY:-

Thick secretions which were colourless from left bronchi and yellow from Right bronchi

No endobronchial growth or lesions seen

On culture and staining of secretions and brushings-
AFB and CBNAAT were negative,
No fungal growth seen.

Klebsiella from left lung and E. coli from right lung were isolated(More likely non-pathogenic)

DIAGNOSIS:

Cryptogenic Organising Pneumonia

 
Treatment : 

Neb. With IPRATROPIUM BROMIDE 4 th hourly.

Tab. PCM 500 mg PO /SOS.

Head end elevation.

Day3

Two episodes of fever spikes present of 100.3 F.

Hemoptysis decreased.

Vomitings and diarrhoea subsided.

Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS IV/OD.

Tab.PCM  650 mg SOS.

Temp charting 4th Hourly.

 On Day4 

C/o generalised weakness.

No fresh complaints.

O/E 

 Vitals

TEMP-98.8 F

PR- 104 bpm

BP- 90/60 mm of hg

RR-24 cpm

 Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO  650 mg SOS

Day 5

C/o generalised weakness.

No fresh complaints.

O/E 

 Vitals

TEMP-98.4 F

PR- 98 bpm

BP- 100/60 mm of hg

RR-28 cpm

 Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

Day 6

Fever +, cough+

O/E 

 Vitals

TEMP-101F

PR- 105 bpm

BP- 110/70 mm of hg

RR-30cpm

 Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO  650 mg SOS

Day7 

Cough +, fever

O/E 

 Vitals

TEMP-101F

PR- 104 bpm

BP- 110/70 mm of hg

RR-28cpm

 Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO  650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Investigations-

T3N3 M0.

Day -8

 Cough +, fever subsided

O/E 

 Vitals

TEMP-101F

PR- 104bpm

BP- 110/70 mm of hg

RR-28cpm

 Treatment:

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Day-9

Cough +, fever  present

O/E 

 Vitals

TEMP-101F

PR- 90bpm

BP- 80/50 mm of hg

RR-26cpm

 Treatment:

INJ. AUGMENTINE 1.2 gm IV /BD( DAY-1)

Neb. IPRATROPIUM BROMIDE 6th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Day-10 

Cough +, fever  present

O/E 

 Vitals

TEMP-100F

PR- 78bpm

BP- 90/60 mm of hg

RR-24cpm

 Treatment:

INJ. AUGMENTINE 1.2 gm IV /BD( DAY-2)

Neb. IPRATROPIUM BROMIDE 1 resp. 6th 

hourly.

Neb. BUDECORT 1 resp. 12th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Day-11 

Cough +, fever  subsiding

O/E 

 

TEMP-99.4F

PR- 68bpm

BP- 80/60 mm of hg

RR-24cpm

Investigations-

 RTPCR - NEGATIVE

Treatment:

INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)

Neb. IPRATROPIUM BROMIDE 1 resp. 6th 

hourly.

Neb. BUDECORT 1 resp. 12th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Day-12

Cough +, fever subsiding

O/E 

 

TEMP-99.4F

PR- 82bpm

BP- 90/70 mm of hg

RR-24cpm

Treatment:

INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)

Neb. IPRATROPIUM BROMIDE 1 resp. 6th 

hourly.

Neb. BUDECORT 1 resp. 12th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr

Day-13

.Cough +, fever subsiding

O/E 

 

TEMP-99F

PR- 82bpm

BP- 90/70 mm of hg

RR-24cpm

Treatment:

INJ. AUGMENTINE 1.2 gm IV /BD( DAY-3)

Neb. IPRATROPIUM BROMIDE 1 resp. 6th 

hourly.

Neb. BUDECORT 1 resp. 12th hourly.

Tab. EVION PO/OD.

Inj. OPTINEURON 1amp in 100 ml NS 

Syp. GRILLINCTUS - BM 15 ml TID

Tab.DOLO 650 mg SOS

IVF 1unit NS. @50 ml/ hr

        1 Unit RL@ 50 Ml/ hr