71 year old with breathlessness

Hall ticket number:1701006050.

G.Sai Vidya

MBBS-IV

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

71 year old male ,Mason by occupation came to OPD  on 1st June,2022 with chief complaints of:

1)breathlessness since 20 days

2)cough since 20 days 

3)fever since 4 days

Timeline of events in this patient:

History of presenting illness:

Pt was apparently asymptomatic 2 months back  then he developed :

•2months back:breathlessness :which is insidious in onset,gradually progressive ,Mmrc grade I,assosciated with dry cough ,he visited to nearby govt hospital,took medications for the same ,symptoms are on and off with medications.

•20days back: breathlessness: progressed to mmrc grade III,breathlessness after walking for some distance,

aggravated on cold exposure and exertion .

Relieved on taking rest.

No orthopnea,PND

Assosciated with right sided chest pain (dragging type of pain)

•20days back: cough with expectoration :

Mucoid ,non foul smelling ,not blood stained ,more during night .

•4days back:fever

Low grade,

Continuous,

Evening rise of temperature ,

No chills and rigors,

Relieved on taking medication .

•history of loss of appetite and loss of weight 

Past history:

No history of similar complaints in the past.

Not a known case of :TB,Asthma,DM,Thyroid ds,HTN

No history of covid19 infection 

Personal history:

Diet:mixed

Appetite:decreased

Bowel and bladder movements:regular

Sleep:adequate

Addictions:smoking since 2yrs (4 beedis /day)

  Drinks toddy from 22yrs of age (1 litre / day)

  Stopped smoking and toddy  since 2 months.

No allergies

Family history:

No history of similar complaints in family members.

General examination:

Pt is conscious, coherent , cooperative.

well oriented to time, place and person

He is thin built and moderately nourished.

.Weight-34 kgs

.Temperature-99°F

.Pulse rate-83 bpm

.Respiratory rate-20 cpm 

.BP-120/80 mm of hg

.SpO2-95%at room air

.GRBS-108mg/dl

.Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- present

.Generalised Lymphadenopathy- absent

.Edema- absent

Systemic examination:

Pt is examined after obtaining consent for the examination ,pt is examined in a well lit room with adequate exposure.

Respiratory system :

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No supraclavicular and infraclavicular hollowing

.No intercoastal indrawing

.No kyphosis and scoliosis

Palpation-

.No local rise of temperature and tenderness

.All inspectory findings are confirmed

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

.AP diameter-23cm

.Transverse diameter-30cm

.Hemithorax diameter on right side is  less than that on the left side.

.vocal fremitus increased on upper part of right side 

Percussion-

.Dull note heard on right upper part of chest

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe 

Clinical images :

CVS:

S1,S2 heard 

No added murmurs .

PER ABDOMEN EXAMINATION :

Soft and 

NO HEPATOSPLENOMEGALY

CNS :

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

Investigations:

HbsAg RAPID:negative

Anti HCV AntibodiesRAPID:negative

HIV 1/2 RAPID: negative 

Sputum for AFB:(ZN staining): no acid fast bacilli seen

HRCT :

Diagnosis:

Right lung upper lobe fibrosis 

Treatment:

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD