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

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

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 , initially it was MMRC grade I to MMRC grade IV 

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

SpO2- 97% at RA 

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

Chest circumference -

On inspiration- 86.cm

On expiration - 86cm

Tactile fremitus - right left  

Supraclavicular increased 

Infraclavicular increased 

Mammary increased

Axillary increased 

Infra axillary increased

Suprascapular increased

Infrascapular increased

Interscapular increased

Vocal resonance -

                                   Right left 

  Supraclavicular Normal increased

  Infraclavicular Normal increased

  Mammary Normal increased 

  Axillary Normal increased 

  Infraaxillary 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 

                                                                                                       

4.AUSCULTATION 

Bronchial breath sounds present on left side 

INVESTIGATIONS:

Hb - 13.5 gm /dl

TLC - 6900 cells /cumm

PLT- 1.60 lakhs / cumm

CUE -

Albumin - nil

Sugars - nil

Bile pigments and Bile salts -nil

Pus cells - 2 to 3 

Epithelial cells - 2 to 3 

RBCs - nil

Casts- nil

Crystals - nil

Amorphous deposits and others - nil

RBS - 114 mg/dl

Serology - negative 

LFT -

TB- 0.94 mg/dl

DB- 0.20 mg/dl

AST- 19 IU/L

ALT- 14 UU/L

ALP- 101 IU/L

TP- 6.8 gm/dl

Albumin- 4.0 gm/dl

A/G- 1.5 

RFT-

Urea - 4.1 mg/dl

Creatinine - 1.1 mg /dl

Uric acid - 5.6 mg/dl

Calcium - 9 mg/dl

Phosphorus- 3.2 mg/dl

Sodium - 136 mEQ/L

Potassium - 3.8 meq/L

Chloride - 101 meq/L