H.no : 1601006064
This is an E log to discuss our patient de- identified health data shared after taking his/her consent
Consent Taken
A 51 year old male patient resident of Miryalguda , farmer by occupation ,presented with a chief complaint of
1. Fever since 10 days
2. Cough with sputum since 10 days
3. Shortness of breath since 7 days
History of present illness
Patient was apparently asymptomatic 10 days back then developed following symptoms
Fever which was insidious in onset and it was not associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication
He then developed Expectorate Cough which gradually progressed more during the nights followed a similar diurnal pattern .The sputum was scanty and yellow which was non foul smelling
Cough was associated with Chest pain which was non radiating in nature and aggrevated on lying down relieved on sitting upright
He later developed gradually Dyspnea which went on to interfere his daily activities (indicating MMRC Grade 3 / 4 ) and eventually progressed to orthopnea
No history of wheeze
Past history
No history of
Asthma
Diabetes Mellitus
Hypertension
Epilepsy
Known history of COPD
Tb 5 yrs back, medication was taken for 2 months and stopped later on as the symptoms subsided
Family history
Not relevant
Personal history
Sleep: disturbed
Bowel and bladder regular
Appetite: normal
Diet: Mixed
No food or drug allergies
Addictions : smoking since 40 yrs ( 10 cigarettes a day )
Smoking index 400
Alcohol since 40 yrs
Differential Diagnosis
TB
Exacerbated COPD
Fibrotic lung disease
Pneumonia
Examination
Patient was conscious coherent and cooperative
Seems to be undernourished
Vitals
Pulse
- 82 bpm
- Regular
- Normal volume
Respiratory rate 29 cpm
On physical examination
Pallor present
Icterus absent
Cynosis absent
Clubbing absent
Lymphadenopathy absent
Edema absent
Systemic examination
Respiratory
Upper respiratory tract examination
- Nostrils : Normal
- Nasal septum: No deviated nasal septum
- Nasal polyps: No nasal polyps
- Tonsils :No enlarged tonsils
- Posterior pharyngeal wall appears to be normal
Inspection
- Shape and symmetry :Elliptical and symmetrical
- Spine: central
- Trachea :Appears to be central
Respiratory movements decreased on both sides
Breathing pattern was Abdomino-Thorasic
No visible pulsations
No visible scars or sinuses
Palpation
Spine is central
Trachea is central
Dimensions AP 16.5
Transverse 23.5
Chest expansion was equal on both the sides
Vocal fremitus was increased on left infra clavicular and mammary region
Apex beat was felt on 5 th intercostal space medial to MCL
Percussion
On percussion dull note was heard on
- Left infra clavicular
- Left mammary
Auscultation
Decreased breath sounds
There was an Increased vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)
No other added sounds heard
Cvs
Normal S1 S2 heard
No murmurs
No jugular venous distension
Apex beat felt on 5 th intercoastal space
CNS
No focal deficits seen
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