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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever
ACKNOWLEDGEMENTS
1)Few of the Images are taken from the following Elog
https://151arushikimari.blogspot.com/2022/06/final-practical-short-case.html
71 year old male with breathlessness
71 yr old male Mason by occupation came to the general medicine OPD on 1st june,2022 with chief complaints of
• Cough since 20 days
• Shortness of breath since 20 days
•fever since 4 days
Daily routine-
He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.
History of present illness-
Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1) and dry cough.
=>2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.
=>20 days back breathlessness was progresses to MMRC grade-2 to 3 (stop for breath after 100 yards of walk )
.Associated with wheeze
.Aggrevated on cold exposure,exertion
.Relieved on rest
.No orthopnea and PND
=>20 days back,he developped cough with expectoration
.Mucoid in consistency
.Non foul smelling
.Non blood stained
.Aggrevated at night
=>4 days back,he developped fever,which is continuous and low grade
.Evening rise of temperature is present
.Relieved on medication
.Not associated with chills and rigors
ASSOSCIATED SYMPTOMS
• Chest pain on right side since 7 days which is of pricking type ,not radiating and not associated with sweating
• Fever since 4 days insidious in onset , relieved by medication
• Patient gave history of loss of weight and loss of appetite
History of past illness-
.No history of similar complaints in the past
.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.
PERSONAL HISTORY
• Appetite : Decreased since 2 months
• Diet : mixed
• Bowel and bladder : on alternate days
• sleep : disturbed due to pain
• Addictions : habit of smoking beedi since 40 yrs and drinks toddy from 22yrs of age, alcoholic on occasions
(~staphed smoking and alchol/ intake since 2 mothns).
FAMILY HISTORY
• No similar complaints in the past or in family members
GENERAL EXAMINATION
Patient is conscious, coherent ,well oriented to time,place,persons
thin built and moderately nourished
Pallor : present
Icterus: absent
Cyanosis: absent
Clubbing : present (grade 2)
Lymphedenopathy : absent
Pedal edema : absent
VITAL SIGNS
Temperature :- afebrile
Respiratory Rate :- 22 cycles per minute (tachypnea)
Pulse:-79 beats per minute
Blood pressure :- 120/80 mmHg
taken from Left arm ,measured in sitting position
DAY 1
BP- 110/80 mm hg
pulse- 88 bpm
respiratory rate -28 cpm
spo2 -96%
DAY 2
BP -120/80 mm hg
pulse -89 bpm
respiratory rate -26 cpm
spo2 -96%
DAY 3
BP -120/80 mm hg
PULSE -94 bpm
RR-14 cpm
SPO2 -92% (on room air )
96% ( with 2 lits of oxygen)
GRB 108mg /dl
DAY 4
BP -120/80 mm hg
PULSE -90 bpm
RR-24cpm
SPO2 -96% (on room air )
DAY 5
BP -120/80 mm hg
PULSE -88 bpm
RR-22cpm
SPO2 -98% (on room air )
DAY 6
BP -120/80 mm hg
PULSE -92 bpm
RR-24cpm
SPO2 -91% (on room air )
97% (with 2 lits of oxygen)
SYSTEMIC EXAMINATION
》》REXPIRATORY SYSTEM
INSPECTION
Upper respiratory tract
Oral cavity -normal
Nose - normal
Pharynx -normal
Shape of chest - Elliptical and bilaterally symmetrical
Trachea - deviated to right side
Movements - reduced on right side
no crowding of ribs
no scars and sinuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscle
No spinal deformities
MOVEMENT OF THE CHEST
Rate : 22 cpm Tachypnoea
Movements decreased on right side
PULPATION
No local rise of temperature
No tenderness
》》 All the inspectory findings are confirmed
Trachea is deviated towards right side (by 3 finger test)
Chest diameters
Transverse :- 27 cm
Anteroposterior :-20 cm
Apical impulse : shifted to right (2 cms medial to mid clavicular line )
Chest expansion :1 cm
Chest movements decreased on right side
NO tenderness over the chest wall
Vocal fermitus :
• Increased on right side at infraclavicular and mammary areas
• normal on left side
PERCUSZION
• Dull note on right side at infraclavicular and mammary areas
• Resonant on left side
ASCULTASION
• Normal vesicular breath sounds heard ,
•Diminished breath sounds in infraclavicular area
•No other added sounds
》CARDIOVASCULAR SYSTEM
INSPECTION
•The chest wall is bilaterally symmetrical
PALPTATION
•Apical impulse is felt in the fifth intercostal space, 2 cm medial to the midclavicular line
• No parasternal heave felt
AUSCULFATION
•S1 and S2 heard, no added thrills and murmurs are heard
》》P/A EXAMINAKION
Soft and no organomegalu
》》CENTRAL NERVOUSB SYSTEM
Higher mental functions are normal
Sensory and motor examinations are normal
No signs of meningeal irritation
.Speech- normal
.cranial nerves- normal
.Motor system- normal
.Sensory system- normal
.Reflexes-normal
.Gait- normal
》INVESTIGATIONS
_HEMOGRAM
COMPLETE URINEX AMINATION
_LFT
2D ECHO
HRCT
ECG
HIV
AFB CULTURE
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 on 5 th June,2022.
.Under ultrasound guidance
.Fluid aspirated was 20 ml
.Straw coloured
PROVISIONAL DIAGNOSIZ
RIGHT Lung UPPER LOBE CONSOLIDATION
TREATMENT
DAY 1
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
>2/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 102 bpm
RR-26 com
SpO2-90% on RA
98% on 2 lit oxygen
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
DAY 2
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
=>03/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 89 bpm
RR-26 com
SpO2-96% on RA
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
DAY 3
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
04/06/2022-
O/E - patient is conscious, coherent, cooperative.
Temperature-98.7°F
BP-120/80 mmHg
PR- 94 bpm
RR-14 com
SpO2-92% on RA
96% on 2 litres oxygen
Respiratory system examination-
Bilateral air entry- present
No added sounds
DAY 4
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
injection optineuron 100ml OD
Syrup Ascoril 2 tspns TID
05/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 90 bpm
RR-24 com
SpO2-96% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
DAY 5
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID , mucomol tid
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
syrup cremaffin 10 ml (per oral )
06/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
DAY 6
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
syrup cremaffin 10 ml (per oral )
07/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
