78 years old male with throat pain, cough, breathlessness

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

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
SPUTUM FOR CULTURE AND SENSITIVITY - POSITIVE
SPUTUM CBNAAT - POSITIVE 
USG Neck - normal study
20/01/23
21/01/23
22/01/23
24/01/23
25/01/23
26/01/23
27/01/23

TREATMENT:
ATT(3Tabs) under NTEP BBF
INJ Pan D 40mg iv od bbf
Syp.Grillinctus Dx 2tbsp po tid
Syp. Aptivarte 2tsp po bd
Tab Benadon 20mg po od
Neb with duolin 8th hrly, budecort 12th hrly
T.glimi M1 po after food ( 8am - x - 8pm)
IVF NS @ 500 ML/ HR
GRBS 6TH hrly monitoring
2 egg white/day





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