CHIEF COMPLAINTS
A 71 year old male patient came to opd with chief complaints of breathlessness and cough since 20 days
HISTORY OF PRESENTING ILLNESS
Patient is apparently asymptomatic 20 days back then he developed cough and shortness of breath.
COUGH
cough is associated with sputum
color of sputum - whitish( Mucoid)
Blood tinged sputum ( 2 to 3 episodes)
not associated with odour
DYSPNEA
insidious in onset
grade III dyspnea (MMRC grading)
breathlessness after walking for some distance.(100 yards)
Associated with right sided chest pain
which is of dragging type.
•Fever since 4 days
insidious in onset , relieved by medication
• Patient have a history of loss of weight and loss of appetite
PAST HISTORY
No history of similar complaints in the past
no history of covid 19 in the past
No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid abnormalities
PERSONAL HISTORY
Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate
Addictions :- smokes 3-4 beedis per day since 50 years. Drinks alcohol occasionally.
He used to work as a construction worker ,later he worked as a security gaurd , recently he worked as a farmer but stopped working 5 days before admitting in Hospital
FAMILY HISTORY
No history of similar complaints in family
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative
Thin built and moderately nourished
Weight 37 kgs
Pallor :- Present
Icterus :- Absent
Cyanosis :- Absent
clubbing :- present (Grade II - Parrot beak appearance )
Lymphadenopathy :- 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
The patient was examined in a well lit room with adequate exposure after taking informed consent
INSPECTION
Upper respiratory tract - Normal
Shape of chest - elliptical & Bilaterally symmetrical
Trachea - deviated to right side
Movements - reduced on right side
no crowding of ribs
no scars and sunuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscles
PALPATION
No local rise of temperature
No tenderness
All the inspectory findings are confirmed
Apical Impulse :- 5th intercostal space 2 cm medial to mid clavicular line
Trachea is deviated towards right side (3 finger test )
chest expansion 1cm ( Inspiration circumference - expiration circumference)
Chest diameters
Transverse :- 27 cm
Anteroposterior :-20 cm
Movements of chest with respiration are reduced on right side
chest expansion 1cm
vocal fremitus - increased on right side
R L
• Supra clavicular normal normal
• Clavicular increased normal
• Infra clavicular increased normal
• Mammary increased normal
• Axillary increased normal
• infra axillary increased normal
• Supra scapular increased normal
• infra scapular Normal Normal
PERCUSSION
supraclavicular, infraclavicular, mammary, axillary, infra axillary, suprascapular, infrascapular areas are percussed
Dull note was noted in Right infraclavicular and suprascapular areas
All other areas were resonant
AUSCULTATION
Normal vesicular breath sounds are heard
decreased breath sounds in Right infraclavicular area and Right Suprascapular area
No added sounds
CVS EXAMINATION
Inspection-
The chest wall is bilaterally symmetrical
Palpation-
Apical impulse is felt in the fifth intercostal space, 2 cm medial to the midclavicular line
• No parasternal heave felt
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
PER ABDOMINAL EXAMINATION :-
Soft and
NO HEPATOSPLENOMEGALY
CENTRAL NERVOUS SYSTEM
Higher mental functions are normal
Sensory and motor examinations are normal
No signs of meningeal irritation
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Right 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
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
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
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
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
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 )
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 )
