SOB with cough and dyspnoea

 

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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 a diagnosis and treatment plan.

1701006097

case details :

A 69 year old male, agricultural labourer by occupation hailing from panthangi  has come to the hospital with the following complaints

1. SHORTNESS OF BREATH SINCE 20 DAYS 

2. COUGH SINCE 20 DAYS

3. FEVER SINCE 4 DAYS

HISTORY OF PRESENT ILLNESS

The patient was apparently alright 20 days ago, then he developed Shortness of breath which was insidious in onset, MMRC grade 2-3 aggravated on Exertion and exposure to cold ,releived on taking rest. There is no history of breathlessness on lying down or Sleep disturbance due to SOB

He also complains of  Cough with expectoration- sputum is mucoid, non blood stained, non foul smelling. No aggrevating factors, releived on rest.

He also complains of fever since 4 days which was insidious in onset, continuous in nature. No Chills and rigors. Fever was releived on taking medication.

Patient gives a history of loss of appetite and loss of weight and also dragging sensation in the right side of chest

The patient denies history of Nasal obstruction,nasal discharge, sore throat, hoarseness of voice , noisy breathing and chest pain 

PAST HISTORY

No history of similar complaints in the past 

No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid problems

Personal history 

Appetite :- Decreased

Diet :-mixed

Bowel and bladder :- regular

Sleep :- adequate 

Addictions :- He smokes 4 beedis per day since 50 years. He takes alcohol occasionally. 

Family history 

No history of similar complaints in family 

GENERAL PHYSICAL EXAMINATION

Patient is conscious, coherent and cooperative 

Thin built and moderately nourished

Pallor :- Present 

Icterus :- Absent 

Cyanosis :- Absent 

Lymphadenopathy :-Absent

Pedal Edema :-Absent 

Vital signs

Temperature :- He is afebrile 

Respiratory Rate :-22 cycles per minute 

Pulse :- 

         Rate :-80 beats per minute 

         Rhythm :- Regular 

         Volume :- normal

         Character :- normal

         Condition of vessel wall :- Normal/soft

         No radio radial or Radio femoral delay  

Blood pressure :-  120/80 mmHg taken from Left arm ,measured in sitting position 

SYSTEMIC EXAMINATION 

The patient was examined in a well lit room after taking a valid informed consent after adequate exposure 

RESPIRATORY SYSTEM EXAMINATION

Upper respiratory tract :- Normal

Examination of Chest 

Inspection

The chest appears to be normal and bilaterally symmetrical

Trachea appears to be central in position 

Apical impulse is seen in fifth intercostal space 

No bony abnormalities of chest 

Movements of chest with respiration appear to be reduced on the right side 

No evidence of usage of accessory muscles for respiration

No scars and sinuses seen 

No dilated veins are seen on the chest wall 

Palpation

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 

Movements of chest with respiration are reduced on right side 

Apical Impulse :- 5th intercostal space 1 cm medial to mid clavicular line

Vocal fremitus -increased in Right suprascapular and right infraclavicular area 

Percussion 

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

Dull note was noted in Right infraclavicular and suprascapular areas  

All other areas were resonant

Auscultation

Normal vesicular breath sounds heard 

Diminished breath sounds in Right infraclavicular area and Right Suprascapular area 

Fine crepitations heard in Right mammary and infra axillary area

Vocal resonance increased in right Infraclavicular and Right suprascapular areas 

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 1 cm medial to  the midclavicular line

No parasternal heave felt

No thrill felt

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

PER ABDOMINAL EXAMINATION :- 

Soft and non tender 

NO HEPATOSPLENOMEGALY

CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

• Patient is conscious  ,coherent and cooperative 
• Right handed individual
• Memory - immediate , short term and long term memory are assessed and are normal 
• Language and speech are normal

Cranial nerves :- intact 

Sensory system :- 

Sensation                  right                   left

 Touch                       felt                       felt

Pressure                    felt                       felt 

Pain 

-superficial              felt                       felt

-deep                         felt                       felt

Proprioception

-joint position         ✔                        ✔

-joint movement    ✔                        ✔

Temperature         felt                      felt 

Vibration                felt                      felt

Stereognosis           ✔                       ✔

Motor system 

                              Right.                  Left

BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N

TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N

POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5

Gait :- Normal

Superficial and deep reflexes are elicited

No signs ssuggestive of cerebellar dysfunction

PROVISIONAL DIAGNOSIS

Right Upper lobe fibrosis 

Investigations 

1.Sputum examination 

Negative for acid fast bacilli 

2. COMPLETE BLOOD PICTURE 

    Hb :- 11.7

    TLC :- 15400

    NEUTROPHILS:-82

    EOSINOPHILS :-01

    BASOPHILS :-00

    LYMPHOCYTES:-10

    MONOCYTES- 7

    PCV:-34.7

    RBC count :- 3.83 millions

    PLATELETS:-2.83 lakhs

3. COMPLETE URINE EXAMINATION:

Normal 

4. ABG

     pH:-7.44

     pCO2 :-34.3

     pO2:-68.3

     HCO3:-23.4 

5. LIVER FUNCTION TESTS

   TOTAL BILIRUBIN :-0.45

   DIRECT BILIRUBIN:-0.17

   AST :-28

   ALT:-27

   ALP:-202

   ALBUMIN:-2.73

  

6.ECG

7. XRAY CHEST 

8. 2D ECHO :- 

No regional wall motion abnormality 

Ejection fraction :-67

Mild diastolic dysfunction present 

Treatment 

1. Inj.Augmentin

2. Nebulisation with Duolin (BD)and budecort (TID)

3.Syp.Chromaffin 10 mL 

4.Monitoring of vitals

5. Spo2 monitoring 

6.Inj- PAN -40  mg OD

7.ASCORIL - CS ( 2 table spoons