A 80yr old male patient came to hospital with complaints of cough and difficulty in breathing

 Hi, this is Anirudh manne, a medical student currently studying in KIMS Narketpally. This page is a compilation of cases taken up during my medical school years, with an intent to correlate theoretical concepts of medicine to practical aspects of it. These E-logs have been created after taking consent from the patient and the patient's advocate. So welcome, and I encourage you to immerse yourselves into these interesting cases.

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 

CHIEF COMPLAINTS of cough and difficulty in breathing since 2 years, which aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive,

No associated wheeze 

No orthopnea 

No seasonal variations, no pnd 

No history of recurrent upper/ lower respiratory tract infections 

Also complaints of cough since 2 years 

Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling

Not associated with blood

Cough aggravated on lying down

No seasonal variations 

No chest pain, palpitations, syncopal attacks 

PAST HISTORY-

K/C/O TB 30 years back, used medication for 4 months 

K/C/O HTN since 5 months 

N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY-

Diet mixed 

Appetite Normal 

Bowel and bladder movements regular

Sleep adequate 

Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION -

Patient is c/c/c , moderately built and nourished 

No pallor, icterus, cyanosis ,clubbing, lymphadenopathy, pedal edema 

Vitals:

Temp- afebrile 

PR- 78bpm

BP- 110/70 mmhg 

RR- 18cpm

 

SYSTEMATIC EXAMINATION 

RESPIRATORY SYSTEM EXAMINATION 

URT-

Oral cavity- hard palate , soft palate, uvula , tonsils , posterior pharyngeal wall - normal 

Dental caries present 

Nose - No septal deviation or Nasal polyps 

LRT

1.INSPECTION -

Shape of the chest - elliptical 

There is drooping of shoulder towards left side

Trachea appears to be central 

Equal movement of chest wall on both sides

No usage of accessory muscles 

No scars ,sinuses ,engorged veins, edema

2.PALPATION -

No local rise of temperature , no tenderness 

Trachea deviated towards the left side

Movement of chest wall - slightly decreased on left side 

AP diameter is 22cm and Transverse diameter is 28 cm

Tactile fremitus            Right        Left  

Supraclavicular        normal       increased 

Infraclavicular          normal.      increased 

Mammar                   normal        increased

Axillary                      normal.      increased 

Infra axillary             normal       increased

Suprascapular          normal       increased

Infrascapular            normal      increased

Interscapular            normal      increased

  

3. PERCUSSION 

                                    Right             left 

 Direct.                        Normal   decreased 

 Supraclavicular         Normal   decreased 

 Infraclavicular           Normal   decreased 

 Mammary                  Normal   decreased 

 Axillary.                     Normal   decreased 

 Infra axillary              Normal     decreased 

 Suprascapular         Normal     decreased 

 Infrascapular           Normal      decreased 

 Interscapular          Normal     decreased

INVESTIGATIONS-