80 year old male with cough and difficulty in breathing since 2 years

Hi, this is Shreshta Reddy Adla, a medical student currently studying in KIMS Narketpally. This page is a compilation of cases taken up during my medical school years, with an intent to correlate theoretical concepts of medicine to practical aspects of it. These E-logs have been created after taking consent from the patient and the patient's advocate. So welcome, and I encourage you to immerse yourselves into these interesting cases.

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of an  80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 

CHIEF COMPLAINTS :

of cough and difficulty in breathing since 2 years, which  aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive,

No associated wheeze 

No orthopnea 

No seasonal variations, no pnd 

No history of recurrent upper/ lower respiratory tract infections 

Also complaints of cough since 2 years 

Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling

Not associated with blood

Cough aggravated on lying down

No seasonal variations 

No chest pain, palpitations, syncopal attacks 

PAST HISTORY 

K/C/O TB 30 years back, used medication for 4 months 

K/C/O HTN since 5 months 

N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY 

Diet mixed 

Appetite Normal 

Bowel and bladder movements regular

Sleep adequate 

Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION 

Patient is c/c/c , moderately built and nourished 

No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy, pedal edema 

Vitals:

Temp- afebrile 

PR- 78bpm

BP- 110/70 mmhg 

RR- 18cpm

 

SYSTEMATIC EXAMINATION 

RESPIRATORY SYSTEM EXAMINATION 

URT

Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 

Dental caries present 

Nose - No septal deviation or Nasal polyps 

LRT

1.INSPECTION 

Shape of the chest - elliptical 

There is drooping of shoulder towards left side

Trachea appears to be central 

Equal movement of chest wall on both sides

No usage of  accessory muscles 

No scars ,sinuses ,engorged veins, edema 

2.PALPATION 

No local rise of temperature  , no tenderness 

Trachea deviated towards the left side

Movement of chest wall - slightly decreased on left side 

AP diameter is 22cm and Transverse diameter is 28 cm

Tactile fremitus -     right         left  

Supraclavicular      Normal            increased 

Infraclavicular       Normal            increased 

Mammary              Normal             increased

Axillary                 Normal              increased 

Infra axillary         Normal                increased

Suprascapular       Normal               increased

Infrascapular            Normal            increased

Interscapular             Normal          increased

  

3. PERCUSSION 

                                 Right       left 

 Direct                   Normal     decreased 

 Supraclavicular   Normal      decreased 

 Infraclavicular     Normal      decreased 

 Mammary            Normal      decreased 

 Axillary                Normal      decreased 

 Infra axillary        Normal      decreased 

 Suprascapular   Normal        decreased 

 Infrascapular     Normal        decreased 

 Interscapular     Normal        decreased

INVESTIGATIONS