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-





















Comments

Post a Comment

Popular posts from this blog

A 60year old man came to hospital with complaints of tremors in right hand

Image
  Hi I am, AnirudhManne (roll no:11), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. A 60year old male agricultural worker by occupation came to hospital with complaints of tremors in right hand Chief complaints Patient complaints of tremors in right forearm and hand History of presenting illness Patient was apparently asymptomatic 2years back He then developed shivering of right hand and arm which was     Insidious on onset and gradually progressive Initally shivering was localised to fingers only, later radiated to Palm.     numbness present Decreased power in right hand inability to hold things,unable to eat food, unable to work.     pain in right thigh     Shivering of right hand aggravated due to stress, anxiety fear, present for sometime during sleep.     Shivering is present throughant the day Intensity increases and dec
Read more

A 40year old male came to hospital with snake bite

Image
  Hi I am, AnirudhManne (roll no:11), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. Chief Complaints: Bilateral loin pain since 3days. History Of Presenting Illness: Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically.  C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down. He has low grade fever,Nausea and vomiting. Not a known case of Burning Micturition,decreased or increased urine output.  No history of cough,cold,body aches,chest pain. Past History: N/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA Personal History: Diet : Mixed  Appetite : Normal Sleep : Normal Bowel and bladder moments :Regular  Addi
Read more

A 65 year old came to casualty on 10/10/2023

Image
Hi I am, Anirudh Manne (roll no:11), 6th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.   A 65yr old male came to casualty on 10/10/23 with history of fall Chief complaints Patient had suffered from fall on 10/10/23 and complains of pain in neck since fall History of presenting illness patient was apparently asymptomatic till yesterday  Patient was brought to casualty with History of fall (slips fall) over the floor on his left side of the face and has    pain in back of the neck unable to    move his right upper and lower limb(weakness) since the event on 10/0/23 at his home at 5:30pm near miryalaguda. pain in back of neck which is loacalised and non radiating severe in intensity Tenderness present on site of pain Past history  Not a known case of  diabetes mellitus Hypertension  Epilepsy Asthma Tuberculosis History of cataract op
Read more