Long case 16010016048

 This is an E log book to discuss our patient de- identified health data shared after taking his/her consent 


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 -  insidious in onset and it was associated with chills and rigors with diurnal variation which was more during the night ,

Relieved on medication 

Then he developed Expectorate Cough which gradually progressed more during the nights followed a similar  diurnal pattern . It aggrevated  during exposure to colder climates .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 

TB

Hypertension 

Epilepsy 

COPD : 6 yrs  recurrent attacks of exacerbation twice a year are seen

Family history

Not relevant 

Personal history 

Sleep         : disturbed due to SOB

Bowel and bladder regular

Appetite   : normal

Diet           : Mixed

No drug allergies

Addictions : smoking  since 40 yrs ( 3 to 4  cigarettes a day )

Smoking index 120 

Alcohol  since 40 yrs  


 


Examination 

 Patient was conscious coherent and cooperative 

Seems to be undernourished 

Vitals 

Pulse

  •  82 bpm
  • Regular
  • Normal volume 
Bp 100/70 mm hg

Respiratory rate 29 cpm 

On physical examination 

Pallor absent

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 Thoracoabdominal

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 purcussion dull note was heard on 

  • Left infra clavicular
  • Left  mammary 
  • Left infra scapular

Auscultation

Tubular breath sounds 

There was an Increased  vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)

Crepitation were felt on left infra axillary region

CVS 

Normal S1 S2 heard 

No murmurs

Apex beat felt on 5 th intercoastal space 

CNS

No focal deficits seen

Investigations

 



 Provisional Diagnosis 

 Consolidation in the left apical region 
Probably due to exacerbated COPD with infective etiology

Differential Diagnosis

Excerbated COPD

Pneumonia 

TB

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