60 year old male with fever and cough since 10 days

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

A 60-year-old male resident of ramannapeta weaver by occupation came to GM opd with chief complaints of cough for 10 days, fever since 10 days and shortness of breath since 10 days.

Patient was apparently asymptomatic 10 days back then he developed cough which is sudden in onset, gradually progressive, productive, associated with chest pain which is dragging type of pain from left lateral side radiating to the front experienced during cough, aggravated on ingesting food or liquids, no known relieving factors.
Sputum is scanty, black coloured, mucoid in consistency, non-foul smelling, non-blood tinged.
Shortness of breath was insidious on onset, gradually progressed from stage 1 to stage 4 according to MMR scale, no known aggravating or relieving factors.
Fever was insidious in onset, continuous from 10 days, non-progressive, associated with chills and rigors, it aggravates during evenings no known relieving factors.
No H/o orthopnoea, no seasonal variation, no H/o vomiting, loose stools

PAST HISTORY

No similar complaints in the past
25 years back he had an exploratory laparotomy and 1 year back he underwent a surgery for intestinal perforation
He has hypertension from 3 years and diabetes from 6 months
Not a known case of epilepsy, tuberculosis, asthma

FAMILY HISTORY

No similar complaints in the family

PERSONAL HISTORY

Diet: Mixed
Appetite: Decreased
Sleep: Disturbed
Bowel movements: Normal
Bladder movements: Normal
Addictions: Smoker for 30 years and stopped 10 years back

GENERAL EXAMINATION

Patient was conscious coherent and comfortable
Poorly built and nourished
No pallor, no icterus, no clubbing, no cyanosis, no lymphadenopathy, no pedal edema






VITALS

Temp: 101.7F
Pulse: 135bpm
Respiratory rate: 28cpm
Blood pressure: 110/70 mmHg

RESPIRATORY SYSTEM EXAMINATION

UPPER RESPIRATORY TRACT EXAMINATION:
No halitosis, no post nasal drip, no dental carries, no DNS, no sinus tenderness

LOWER RESPIRATORY TRACT EXAMINATION:
INSPECTION:
Chest is symmetrical, elliptical in shape
Trachea appears to be midline
No apical impulse is seen
No drooping of shoulder, no kyphosis, no scoliosis
Increased hollowing of supraclavicular fossa on the right side
No Pectus carinatum, No pectus excavatum
No sinuses, dilated veins, nodules
Scars due to a skin infection is seen
Decreased chest movement on the left side

PALPATION:
All inspector findings are confirmed
Trachea is midline
There is no local rise of temperature or tenderness
No overcrowding of ribs
Anteroposterior diameter is 17cms and Transverse diameter is 26cms
Vocal fremitus equal on both sides on all areas

PERCUSSION:
Dull note heard on the left inframammary, infraaxillary and infrascapular areas
No percussion tenderness is seen

AUSCULATATION:
Normal vesicular breath sounds heard on the right side
Crepitations are heard on the left inframammary, infra axillary and infra scapular areas
Vocal resonance is decreased on the left infra mammary, infra axillary and infra scapular areas

CARDIOVASCULAR SYSTEM
S1, S2 heard, no murmurs heard.

ABDOMEN
Scaphoid in shape, soft, non-tender, no organomegaly

CENTRAL NERVOUS SYSTEM
Patient is conscious, coherent, and comfortable
Cranial nerves intact
Sensory system intact
Motor system tone, bulk, and power normal on all four limbs

DIAGNOSIS
Left lower lobe lung cavitation

INVESTIGATIONS

XRAY



COLOUR DOPPLER 2D ECHO



ABG



 RBS



COMPLETE BLOOD PICTURE


TREATMENT

IONS bolus
Inj. PIPTAZ
Inj. PAN
TAB. Dolo

 

 



 


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