A 75 year old M with SOB and Cough

 Medical case discussion 

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        CASE DISCUSSION

A 75year old came to the OPD with

Chief complaints of:

Shortness of breath since 6days

Cough since 6days

HOPI:

Patient was apparently asymptomatic 6days back then he developed shortness of breath  

(Grade 2) according to MMRC, aggravated on exertion and relieved on sitting position or inhaler usage.

H/o cough(continuous) with sputum which is white in colour,mucoid, non blood tinged and 

non foul smelling, aggravated on exposure to dust or cold, relieved on medication.

Their is low grade fever which was intermittent with no diurnal and nocturnal variation.

Associated with orthopnea

No history of PND

No H/o cough, hemoptysis,

No h/o chest pain,giddiness , palpitations, decreased urine output, wheeze

No h/o abdominal distension, jaundice, Vomitings 

Past history:

Similar complaints in past since 40year started using inhaler since 20years, more usage in winter

(Aerocort)

Seasonal variation present 

H/o usage of ATT(for 3months)- 6yrs back

Not a K/C/O Diabetes, Hypertension CAD,

Epilepsy 

Personal history:

Diet:Mixed 

Appetite:normal

Sleep-disturbed 

Bowel movements-regular

Bladder movements- normal urinary output

No Addictions

Family history: Not significant

General examination:

Patient is conscious,coherent,cooperative and well oriented with time,place,person

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,

lymphadenopathy 

Edema of feet- present 

Vitals:

Temperature: 98.4 degree Fahrenheit

BP-120/80mmHg

PR-104bpm

RR- 21cpm

Grbs- 160mg/dl( diagnosed de-novo diabetes in our institute)

Systemic examination:

Respiratory system:

Inspection-

Upper respiratory tract- nose, oral cavity and posterior pharyngeal wall- normal

Trachea-appears to be central

Chest appears b/L symmetrical and elliptical in shape 

Chest expansion equal on both sides

(Abdomino- thoracic type of breathing)

No Kyphosis, Scoliosis 

No scars, sinuses, visible pulsation 

Apex beat not appreciated

No wasting of muscle

Palpation-

All Inspectory findings are confirmed 

No local rise of temperature 

No tenderness

Trachea central in position 

Measurements- 

AP diameter - 26cms 

Transverse diameter - 29cms 

Apex beat- felt at 5th ICS, 1cm medial to 

mid-clavicular line

Tactile vocal Fremitus     

                                 Right              Left

Suprascapular           N                    N

Infrascapular       Increased bilaterally  

Percussion  :            Right              Left

Supraclavicular              Resonant                

Infraclavicular            R                    R

Mammary                   R                    R

Axillary                         R                   R

Suprascapular            R                   R

Infrascapular               D                    D

Auscultation :   

                                 Right              Left 

Supraclavicular     NVBS              NVBS

Infraclavicular       NVBS              NVBS

Mammary              NVBS              NVBS

Inframammary      NVBS              NVBS  

Axillary                   NVBS              NVBS

Infra axillary          Crepitations  heard              

Suprascapular       NVBS              NVBS

Infrascapular           Crepitations heard    

Vocal Resonance:

 Infra-scapular-Increased bilaterally 

Provisional diagnosis:

  Pneumonia

Investigations :

Final Diagnosis:

Consolidations secondary to pneumonia