78 years old male with throat pain, cough, breathlessness

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I've 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 a diagnosis and treatment plan.

K.Vyshnavi

Roll No - 70

PATIENT CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF :

C/O Breathlessness since 7days

C/O Cough since 7days

C/O Throat pain since 3 months

Patient was apparently alright 3months back the he developed throat pain since 3 months, insidious in onset, gradually progressed. Dysphagia positive to both solids and liquids.

C/O Breathlessness since 7 days, insidious in onset, gradually progressive (MMRC GRADE- 2), aggrevated on exposure to cold, seasonal variation present, associated with wheeze, no PND no orthopnea

C/O cough since 7 days which is dry, no seasonal and diurnal variation, continuous, no aggrevating and relieving factors

C/O fever occasionally not associated with chills and rigor, but evening raise of temperature positive.

C/O loss of appetite and loss of weight present

No C/O chest pain, chest tightness,hemoptysis

PAST ILLNESS:

H/O PTB 4 years back confirmed by sputum cbnaat and took ATT for 3 months and discontinued and 2 years back for 6 months

H/O similar complaints in past (3years back)

Inhaler usage present on and off, last usage one day before admission

K/C/O DM and on medication ()

N/K/C/O HTN, Thyroid disorder, CAD, Epilepsy

PERSONAL HISTORY

Appetite -Normal

Diet - Mixed

Sleep - adequate

Bowel and bladder movements -Regular (burning micturition+)

Addictions: 2 packs per day beedi, stopped 10 years back, occasionally alcoholic

Allergies : No allergies

GENERAL EXAMINATION:

Patient is conscious ,coherent , cooperative, thinly Built and mildly Nourished .

He was examined under well lit room with consent taken

VITALS ( on admission)

Temp: 99F

BP : 120/70 mmHg

PR : 130bpm

RR : 20cpm

SpO2: 92%@ RA

Weight- 38kgs

Pallor : absent

Icterus : absent

Cyanosis: absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

RS :

INSPECTION:-

URT:

Nose - DNS to right side and left turbinte hypertrophy

Oral cavity- poor oral hygiene, nicotine stained, posterior pharyngeal wall- normal

LRT:

Shape of chest- symmetrical and elliptical

Trails sign negative

Supra clavicular, infra clavicular hollowness - negative

Chest expansion equal on both sides

No crowding of ribs, drooping of shoulders

Wasting of muscles- negative

No usage of accessory muscles on respiration

Spino scapular distance is equal on both sides

Apical impulse - not seen

No kyphosis, scoliosis, sinuses,scars, engorged veins, visual pulsations

PALPATION:-

All inspectory findings are confirmed

Trachea- central, swelling positive in midline

Apex beat is at left 5th ICS, 1 inch medial to mid clavicular line

Tactile vocal fremitus: increased @ Left ICA, MA, INFRA SA, INFRA AA

AP DIAMETER- 19cm

Chest circumference- 73cm

Transverse- 22cm

Rt hemi thorax- 39cm

Lt hemi thorax- 37cm

PERCUSSION -

Direct- Resonant

Mediated- Impaired@ left ICA,MA, IAA, ISA, Infra SA

CVS : S1 S2 + ,no murmurs

P/A : Soft and non tender, no organomegaly

CNS: NFD

PROVISIONAL DIAGNOSIS-

Left sided fibrosis (LL> UL) with COPD with 2° infection ? TB with DM- II

INVESTIGATIONS

2D ECHO

Aortic valve - Sclerotic

No RWMA

EF 60%

Mild to moderate TR with PAH Diastolic dysfunction

HRCT OF THORAX-

Fibrocavitatory changes with traction bronchectasis in both upper lobes with significant volume loss of left lower lobe

Multiple centrilobular nodules in both lungs

Diffuse smooth pleural thickening seen in left costal margin of pleura with few pleural calcification with loculated fluid collection suggestive of fibrothorax/chronic empyema