80 year old male with cough and difficulty in breathing since 2 years


 Hi, this is Anupreethi Reddy, 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-




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