1. Step 1
1.1. problem
1.1.1. SOB grade 4, couph, fever, sore throat, swats
1.2. differential
1.2.1. pneumonia
1.2.1.1. TB
1.2.1.2. CAP
1.2.2. exacerbation of COPD
1.2.3. bronchitis
1.2.4. HF
1.2.5. malignancy
1.2.6. PE
2. Step 2: History
2.1. History of present illness
2.1.1. smoker 90 pack years
2.1.2. rihnorrhea
2.1.3. sore throat
2.1.4. low grade fever 1 week ago
2.1.5. followed by couph
2.1.5.1. no hemoptesis
2.1.5.2. sputum became discolored
2.1.6. SOB strarted only on excretion, now at rest
2.1.6.1. in the last 4 days
2.1.7. unable to lie flat
2.1.8. soft weeze
2.1.9. no chest pain
2.1.10. no leg swelling
2.1.11. relived by blue puffer
2.1.11.1. not as effective lately
2.2. system review
2.2.1. no change on wight
2.3. Past history
2.3.1. long standing smoker couph, less than tea spoon per day
2.3.2. PND last several months
2.3.3. able to walk 400 meters (before illness)
2.3.4. HF
2.4. Medications
2.4.1. sulbutamole inhalor
2.4.2. no allergies
2.5. Family
2.5.1. stroke in mother at 65
2.5.2. father died of accedent
2.6. Social
2.6.1. alcohol 120 g per day, stopped 17 years ago. now 31 g per day
2.6.2. seperated from his wife
2.6.3. bus driver (retired)
3. Step 3: Problem formulation
3.1. problem
3.1.1. 63 years old male heavy smoker and drinker kc of HF presented with SOB grade 4 for 1 week, fever, couph with yellow sputum, and sweats
3.2. differential
3.2.1. Exacerbated COPD with respiratory failure
3.2.2. decompensation of HF
4. Step 4: Examination
4.1. General
4.1.1. vitals
4.1.1.1. 37.7
4.1.1.2. 110 KG
4.1.1.3. 177 cm
4.2. MSK
4.3. Cardiac
4.3.1. 110 reg
4.3.2. 145/85 BP
4.3.3. JVP not raised
4.3.4. apex not palpable
4.4. Lung
4.4.1. 30 RR
4.4.2. barrel chest
4.4.3. accessory muscle use
4.4.4. pursed lip
4.4.5. auidible wheeze
4.4.6. no clubbing
4.4.7. mild cyanosis
4.4.8. increased percussion
4.4.9. mid inspiratory crackles (basal)
4.5. abdominal exam
4.5.1. liver span 15 cm
5. Step 5: Refinement of differential diagnosis
5.1. infective exacerbation of COPD
6. Step 6: Investigations
6.1. CBC
6.1.1. wbc 9.7
6.1.2. neutrophils 86%
6.1.3. lymph 7%
6.1.4. hb 175
6.1.5. plt 355
6.2. biochem
6.2.1. na 141
6.2.2. k 4.8
6.2.3. cl 104
6.2.4. bicarb 30
6.2.5. urea 9.5
6.2.6. cr 89
6.2.7. albomin 40
6.2.8. protein 85
6.3. sputum gram stain
6.3.1. gm+ cocci
6.4. blood culter
6.5. ABG
6.5.1. o2 sat 71%
6.5.2. bicarb 30.2
6.5.3. ph 7.3
6.5.4. pco2 58
6.5.5. po2 51
6.6. spirometry
6.6.1. 0.75/1.75
6.6.1.1. 0.42
6.6.1.2. obstructive
6.7. lung x ray
6.7.1. hyperinflated
6.7.2. flattend diaphragm
6.7.3. reduced bronchovascular marking in upper zone
6.8. ECG
6.8.1. right ventricular hypertrophy