71 year old male with chief complaints of breathlessness and cough since 20 days

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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 diagnosis and treatment plan.

A Shishira Reddy

1701006005

Chief complaints-

A 71 year old male ,Mason by occupation came to the general medicine OPD  on 1st June,2022 with chief complaints of

. breathlessness since 20 days

.cough 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 10pm 

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) 

2 months back, he visited near by government hospital where he was given medication. Symptoms were relieved temporarily. 

20 days back breathlessness was progresses to MMRC grade-2 to 3

.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 developed fever,which is continuous and low grade 

.Evening rise of temperature is present

.Relieved on medication

.Not associated with chills and rigors

General examination-

Patient is conscious, coherent , cooperative.well oriented to time, place and person

He is thin built and moderately nourished.

.Temperature-99°F

.Pulse rate-83 beats per minute

.Respiratory rate-20 cycles per minute

.BP-120/80 mm of hg

.SpO2-95%at room air

.Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- absent

.Lymphadenopathy- absent

.Edema- absent

Systemic examination-

Respiratory system-

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No kyphosis and scoliosis

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No usage of accessory muscles

Palpation-

.All inspectors findings are confirmed

.No local rise of temperature and tenderness

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

Vocal fremitus on the right upper lobe 

Percussion-

.Dull note heard on right upper part of chest

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe 

.crepitations present on right mid axillary area

CVS-

.S1 and S2 heard

.No murmurs

Per abdominal examination-

.Shape of the abdomen- scaphoid

.Soft,non tender,no organomegaly

.Bowel sounds- heard

Provisional diagnosis-

Right lung upperlobe consolidation

Investigation

CBP 

CUE 

Culture

LFT

HRCt

Treatment 

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD