Consolidated left apical region of lung -by- 1601006138

-

PAWAN BHASIN

HALL TICKET NUMBER - 1601006138

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

No relevant  family history

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 ( 3 to 4  cigarettes a day )

      Smoking index 120 

      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 

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

TREATMENT
-First line- broncho dilators short acting -salbutamol nebulization
-Steroids
-Anticholinergic inhalers include tiotropium (Spiriva), ipratropium.

Comments

Post a Comment

Popular posts from this blog

44 YEAR OLD WITH SHORTNESS OF BREATH

-
Image
A 44 year old male patient it came to casualty with  C/o shortness of breath (grade II) according to NYHA classification Not associated with orthopnea/PND. C/o B/L PEDAL EDEMA ( pitting type ) since 1 week  C/o decreased URINE OUTPUT since 1 week C/o FACIAL PUFFINESS since 1 week  Pt was apparently asymptomatic 1 week back then developed fever associated with chills and rigor, was diagnosed with typhoid and was treated outside in a private hospital  Pt also C/o loss of appetite, and 2 episodes of vomiting ( non bilious , non projectile ) not A/W nausea. Pt is a K/C/O  -CKD since 10 years on regular medication  - DM since 4-5 years  (on GLIMI M2 morning and GLIMI M1 night) -HTN since 1 year - on Tab TELMA-AM NO SIGNIFICANT FAMILY HISTORY PERSONAL HISTORY O/E- Pt is c/c/c obese , clubbing present TEMP+98.4°F BP-130/80MMHG PR-89 BPM RR- 20CPM SPO2-98% @ RA CVS-S1S2 HEARD NO MURMUR RS-NVBS + NO CRYPTS P/A-SOFT, NON TENDER CNS-HMF INTACT APEX BEAT- 6TH ICS LATERAL AND OUTWARD JVP-RAISED , E
Read more

PRE -RENAL AKI 2° to DEHYDRATION with HYPOVOLEMIC SHOCK with ALCOHOLIC KETOACIDOSIS with WERNICKES ENCEPHALOPATHY with ACUTE HEART FAILURE with EF-45% with REFRACTORY METABOLIC ACIDOSIS with H/O PULMONARY KOCH'S (3Y BACK) with K/C/O ASTHMA (4Y BACK) with K/C/O DM(6Y BACK)

-
Image
55 YEAR OLD FEMALE CAME TO THE CASUALTY WITH  c/o shortness of breath since 4 days  ( grade 4 ) acc to NYHA classification not associated with orthopnea /PND  c/o vomiting since 1 day (5-6 episodes ) non projectile,non bilious ,food particles as content associated with pain abdomen  c/o fever since 2 days ,low grade,not associated with chills and rigor  c/o decreased appetite since 3 days  H/O drinking alcohol since last 10 days without eating anything else K/C/O Asthma since 4 years   H/O Pulmonary kochs 3 years back used ATT for 6 months  K/C/O  DM since 6 years on TAB. GLIMI-M2 O/E: Vitals on Admission BP-Not recordable  PR- 121 BPM  RR-22 CPM  SPO2-98 @ GRBS -254 No pallor Icterus cyanosis clubbing lymphaedonopathy and oedema  CVS: S1S2  heard ,no thrills ,no murmers RR: Dyspnoea present        No wheeze         BAE  positive ,NVBS   P/A: soft ,non tender          BS- sluggish  On admission Ur : 63 Cr:1.9 UA:4.9 SERUM ELECTROLYTE  Na-138 K-4 Cl-98 Aftr 1 session of dialysis (7pm) U
Read more

Altered sensorium secondary to Alcohol withdrawal seizures with HFrEF secondary to Beri Beri(wet)

-
Image
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. A 32 yr old male, paint shop worker, came to casuality with  Unresponsiveness since 2-3 hours with passing urine  in clothes after involuntary movements.         Chronic alcoholic since the time of marriage(10yrs), quantity ~ 1  full bottle / day (exact quantity unknown), had a binge consumption of alcohol since yesterday morning, with no intake of food.           Pt was alone at home this           morning; after consumption of alcohol, alleged history of fall, associated with  1 episode of GTCS & feothing, tongue bite, uprolling of  eyes, passed urine in the clothes, and was brought to casuali
Read more