71 year old male with breathlessness

Name - K.Keshitha 

Hall ticket number- 1701006086

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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 diagnosis and treatment plan.

CHIEF COMPLAINTS:

A 71 year old male ,Mason by occupation came with chief complaints of

breathlessness since 20 days

cough since 20 days

fever since 4 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back,then he developed breathlessness which was insidious in onset, gradually progressive which aggrevated with activity and relieved with rest.

He complains of cough with out expectoration with no diurnal variation .

20 days back he developed breathlessness again which

Aggrevated on exertion and Relieved on rest

Not associated with orthopnea and PND

20 days back,he developped cough with expectoration

Mucoid in consistency ,Non foul smelling , non blood stained which aggrevated at night .

4 days back,he developed fever,which is continuous and low grade with evening rise of temperature which relieved  on medication not associated with chills and rigors and body pains.

PAST HISTORY:

No history of similar complaints in the past

Not a known case of TB,Asthma,Hypertension,Diabetes mellitus,COPD.

PERSONAL HISTORY:

Appetite-decreased since 2 months

Diet - mixed

Sleep-adequate

Bowel movements-regular

Bladder movements-decreased urine output since 15 days associated with burning sensation

Addictions-smoking since 3years (4 beedies per day)

  toddy from 25 years (1 litre per day)

Stopped smoking and toddy since 2 months.

FAMILY HISTORY:

No history of similar complaints in the family members.

GENERAL EXAMINATION:

Patient is conscious, coherent , cooperative

He is thin built and moderately nourished.

Vitals : 

Temperature-99°F

Pulse rate-83 beats per minute

Respiratory rate-20 cycles per minute

BP-120/80 mm of hg

SpO2-95%at room air

GRBS-108mg/dl

Pallor- absent

Icterus-absent

cyanosis- absent

Clubbing- absent

Lymphadenopathy - absent

Edema - absent

SYSTEMIC EXAMINATION: 

RESPIRATORY EXAMINATION:

Inspection-

Shape of the chest-,elliptical

Chest is bilaterally symmetrical 

Trachea- appears to be central.

Chest movements-decreased on right side

No chest deformities.

No kyphosis and scoliosis

No crowding of ribs

No scars,sinuses,visible pulsations,engorged veins

No drooping down of shoulders

No supraclavicular and infraclavicular hollowing

No abnormal breathing pattern 

Palpation-

All inspectors findings are confirmed

No local rise of temperature and tenderness

Trachea-shifted 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 reduced on apical part of right side of chest

Percussion-

Dull note heard on right upper part of chest

Auscultation-

Normal vesicular breathsounds heard

Decreased breath sounds on right upper lobe 

crepitations present on right mid axillary area

Vocal resonance- reduced on right apical area.

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest- elliptical 

No precordial bulge or pulsations 

JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

On auscultation :

S1 S2 heard  

No murmurs

PER ABDOMEN:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 

          Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - tympanic note heard 

Auscultation- normal bowel sounds heard. 

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

PROVISIONAL DIAGNOSIS:

Fibrosis of right upper lobe

CBP-

CUE-

LFT-

2D echo-

ECG-

X ray :

AFB Culture:

No acid fast bacilli detected.

RFT-

Urea-31 mg/ dl

Creatinine-0.9

Uric acid-3.1

calcium- 10

phospate-3.3

sodium-128

chlorine-95

potassium-4.2

ABG-

pH-7.44

pCO2-34.3

pO2 -68.3

HCO3-23.4

Needle thoracocentasis was done under ultrasound guidance aspirated 20 ml of fluid which was Straw coloured

Final diagnosis-

Right lung upperlobe 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