70 YR OLD MALE WITH CHEST PAIN COUGH SHORTNESS OF BREATH

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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.

 70 year old male came  to OPD with 

CHEIF COMPLAINTS : 

 1.Chest Pain since 10 days 

2.Cough since 10 days 

3.Shortness of breath  since 8-10 days

4. Fever since 1 week

Hopi-

Patient was apparently asymptomatic 10 days back then he developed cough which  is productive with black coloured mucoid sputum , insidious in onset and gradually progressive, diurnal variations present more during night. 

No seasonal variations. 

No aggravating or relieving factors.

Chest pain is left sided non radiating type not associated with excessive sweating, palpitations,pedal edema,giddiness

Shortness of breath  since 8 days  which is. insidious in onset and gradually progressive,progressed from grade 1 to grade 3 .

No orthopnea,no Paroxysmal nocturnal dyspnea 

No seasonal variation,no diurnal variation.

Fever since 1 week ,high grade associated with chills and rigors

Evening rise of temperature present, loss of weight present

loss of appetite present

No h/o vomiting,loose  stools , pain abdomen.

PAST HISTORY : 

Kwon case of  HTN since 2 years

Known case if DM since 6 months

Not a known case of  Asthma , TB ,Epilepsy and thyroid disorders 

SURGICAL HISTORY : 

Patient underwent exploratory laparotomy for intestinal perforation

PERSONAL HISTORY : 

Appetite- normal

Diet - mixed

Bowel and bladder - regulaR

Addictions- alcohol- regular

Smoking - smoker for 30 years

Stopped 10 years ago

No known history of allergy to drugs 

FAMILY HISTORY :

Not significant 

General Examination : 

Patient is conscious,coherent and cooperative 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

VITALS : 

Temp - 96.8 F

PR- 96 bpm

Bp- 110/70 mmhg

RR -26 cpm

Spo2-97%

SYSTEMIC EXAMINATION : 

RESPIRATORY SYSTEM : 

INSPECTION : 

UPPER RESPIRATORY TRACT : 

Deviated nasal septum -Present towards right side 

No post nasal drip 

LOWER RESPIRATORY TRACT : 

Trachea -Midline 

 Shape of chest : Elliptical 

No drooping of shoulders 

Supraclavicular Hallowing on the Right side is present 

Apical Impulse -Absent 

No intercoastal indrwaing ,Crowding of ribs 

Winging if scapula -Not seen 

No sinuses ,scars ,Dialated veins , Nodules are seen 

Movement of the chest with respiration is normal 

PALPATION : 

All the inpectory findings are confirmed by palpation 

Trachea -central 

No intercoastal widening and tendernesses is seen 

No dialted viens 

Chest movements : 

Decreased chest movements on respiration on the left infra mammary region and Infra-scapular region 

Measurements of chest : 

Transerve diameter : 27 cm 

Anterio -Posterrior diameter : 15cm 

Vocal Fremitus : 

Decreased on the left inframammary and inter scapular and infra scapular regions of the left side 

PERCUSSION : 

Dullness is present on mammary ,interscapular ,infrascapular regions on the left side 

Auscultation : 

Crepitations are heard on infrascapular and mammary regions 

CARDIO VASCULAR SYSTEM : 

S1 S2 heard 

No murmurs 

GASTROINTESTINAL SYSTEM : 

P/A- soft, non tender

CENTRAL NERVOUS SYSTEM : 

No focal neurological Deficit 

INVESTIGATIONS : 

PROVISIONAL DIAGNOSIS : 

Left lung lower lobe cavitation secondary to  TB with type 2 DM and HTN with AKI