long case

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 which was insidious in onset and it was 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 . 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 food or drug allergies 

Addictions : smoking since 40 yrs ( 10 cigarettes a day )

      Smoking index 400

                      Alcohol since 40 yrs  

Differential Diagnosis

Excerbated COPD

Pneumonia 

TB

 

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

 

Diagnosis Fibrosis in the left apical region Probably due to exacerbated COPD