83 year old male with breathlessness since 10 days
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VISHAL SARDA
ROLL NO:-93
UNIT-I
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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS .
CHIEF COMPLAINTS:-
Cough since 14 days,fever since 12 days, shortness of breath since 10 days
HISTORY OF PRESENTING ILLNESS:-Patient was apparently asymptomatic 14 days back then he developed cough which was insidious in onset , gradually progressive associated with sputum which was white in colour,copious amount,mucoid in consistency and non foul smelling.
Patient complained of intermittent spikes of fever since 12 days , associated with chills and rigors , not relieved on medication and not associated with headache and vomiting.
Patient complained of breathlessness since 10 days, which was insidious in onset and gradually progressive from grade -II to grade -IV ,continuous and present during rest with no associated relieving factors. Patient attender also complained of awakening at night due to breathlessness.No h/o palpitations, stridor, hoarseness of voice.
No h/o chest pain, orthopnea, PND, recurrent sorethroat or cold.
PAST HISTORY:-
No h/o similar complaints in the past.
N/k/c/o hypertension,diabetes mellitus, TB, epilepsy, bronchial asthma, thyroid disorders.
No h/o any blood transfusions and surgeries.
PERSONAL HISTORY:-
Told by the attender.
Diet- mixed
Appetite- decreased
Sleep - adequate
Bowel and bladder movements - regular
Addictions-consumption of alcohol occasionally , h/o smoking since 30 years (3 packs/day) reduced to 1 pack per day since 2 years.
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative and well oriented to time, place and person
He is moderately built
There is presence of pallor ,
Pedal edema up to the knee.
No icterus
No cyanosis,
No clubbing
No lymphadenopathy
Vitals :
Temp - afebrile
BP - 130/90 mm hg measured on Left upper arm in supine position
Pulse rate - 78bpm , regular rhythm , normal character, high volume, no radio-radial and no radio-femoral delay
RR- 15cpm
SYSTEMIC EXAMINATION :
RESPIRATORY SYSTEM :
Upper respiratory tract :
Nose : no abnormality detected
Oral cavity : whitish plaques like lesions distributed over the oral mucosa ( Oral candidiasis ?)
Examination of chest proper :
Inspection :
1. Shape of chest - elliptical
2. Trachea position-central
3. Apical impulse - not seen
4. Movements of chest : abdominothoracic type of respiration, with indrawing of intercostal space.
5. Skin over chest : no redness ,engorged veins ,sinuses ,nodules ,scars and swellings.
6 . Abdominal quadrants moving equally with respiration
Palpation :
All inspectory findings are confirmed.
No local rise of temperature and tenderness
Percussion : Dull note in right basal region
Auscultation :
1. Breath sounds- right side crepitations heard , prominent near basal region of lung and in infra axillary region- fine crepts
left side normal breath sounds
2. No other abnormal sounds heard
On admission - chest xray showing bilateral infiltrates with consolidation
P/A : scaphoid, soft, non tender, bowel sounds are heard
Dvl referral was done I/v/o lesions in mouth
Which was diagnosed as oral candidasis
Advised -candid mouth plant l/A bd -2 weeks
Betadine gargle-3 times in a day
Bronchoscopy was done-white plague visualised near vocal cords and left pyriform fossa
Bronchoscopy video link:-
https://youtu.be/FXdsEF4PELw?feature=shared
Investigations:-
Provisional diagnosis: community acquired pneumonia.
Treatment given: DNS,RL @75ml /hr
Inj.piptaz 4.5g iv 8 hrly
Tab.levofloxacin 750 mg po/od
Tab.bactrim-ds 800/160 po/bd
Cap.flucanazole 200mg po/od
Cap.doxycycline 100 mg po/bd
Inj pan 40 mg iv/od
Inj.neurobion 1 amp in 1000 ml ns
Syp.grillinctus 15ml po/tid
Neb.ipravent-8th hrly
Budecort-12th hrly
Tab-dolo 650mg po/tid
candid mouth plant l/A bd -2 we
eks
Betadine gargle-3 times in a day
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