82 year old presenting with sob (prefinal)

Date 15 june,2023

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chief complaints

A 82 year old male comes to the opd with the chief complaints of shortness of breath since 20 days and cough with sputum from 20 days and a episode of fever 10 days ago 

history of present illness:

   The pt was apparently asymptomatic 20 days ago the he developed shortness of breath grade 1 MMRC scale (sob while hurrying or on exertion)  sob was not associated with wheezing .The sob was aggravated on exertion and was relieved on medication

   cough with sputum- mucoid, non purulent, non blood stained sputum was present from 20 days cough aggravated on exposure of dust and was relieved on medication. Cough is associated with sputum, cough is aggravated after eating meal. An episode of cough with sputum lasting 2-5 minutes every 2-3 hours was reported by the patients care taker. Cough and sputum without diurnal, seasonal, positional variation

   Fever 10 days back, 1 episode of low grade fever which was relieved on medication

No history of chest pain, palpitations

No history of pedal edema, ascites, pain in abdomen

past history:

 The pt was diagnosed with chronic kidney disease 10 years ago which is under resolution, the pt has undergone dialysis 3 times around 5-6 years ago 

the pt was admitted in the hospital for 15 days 10 years ago due to malaria, treatment was taken outside and completely resolved.

no similar complaints in the past 

no history of diabetes, hypertension, asthma, CAD, epilepsy

Personal history:

Diet- mixed

Appetite- decreased

Bowel- history of hard stools

Bladder- history of decreased urine output (oliguria) , no history of burning micturition 

Addictions-

The pt is a known smoker from 70 years smoking since the age of 12 years old.

The pt started smoking under bad influence to lift up the mood and was addicted to smoking later, the pt tried to quit smoking several times but was unsuccessful, the pt smokes 1 pack (10 cigaretts) a day

The pt gives a history of alcohol consumption from the past 20 years, occasional drinker drinks around 90-120 ml per session and has a session frequency of around 2-3 times a month from the past 20 years 

Pt’s daily routine:

Wakes up around 4-5 AM and walks around in the house eats home cooked food for breakfast around 10Am then he just lie down or talk to relatives and haves home cooked lunch around 12-1 PM, the pt was a farmer before but now due to old age he stays home, pt will not have any food in the evening usually and had dinner by 8-9 PM and does his work and sleep around 10PM

The pt smokes 10 cigarettes/ day

Family history:

No similar complaints in the family

General examination:-

Vitals-

temperature- afebrile

respiratory rate- 19 cycles per minute

pulse- 76 beats per minute

blood pressure- 110/70 mmhg

spo2- 98%

no history of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

Systemic examination:-

respiratory system-

upper respiratory tract-

oral hygiene- good oral hygiene, lost front 2 tooth due to old age

oral thrush- absent

post nasal drip- absent

pharyngeal depositions- absent

tonsils- normal

dental caries- absent

deviated nasal septum- absent

nasal polyps- absent

lower respiratory tract-

inspection-

chest is symmetrical

trachea appears to be central

apical impulse appears to be in the 5th intercostal space

drooping of shoulders absent

supra/infra clavicular hallowing- absent

crowding of ribs absent

kyphoscoliosis absent

winging of scapula absent

no scars, sinuses, dilated veins or nodules

symmetrical movements of chest with respiration

normal respiration without the use of accessory muscles 

palpation-

trachea central

crowding of ribs absent

kyphoscoliosis absent

dilated veins absent

apical impulse present at 5th intercostal space 

measurement of chest expansion 5 cms

Transverse diameter-31.5 cms

A-P diameter- 23.5cms

Around the chest measurement- 90 cms

percussion-

part                                                 left                        right

clavicular                                resonant                 resonant

kronigs isthmus                      resonant                 resonant

infra clavicular                       resonant                 resonant

mammary                               resonant                 resonant

axillary                                   resonant                 resonant

infra axillary                          resonant                 resonant

supra scapular                        resonant                 resonant

infra scapular                         resonant                 resonant

interscapular                          resonant                 resonant

tidal percussion is normal

percussion tenderness absent

no dullness present

auscultation- 

breath sounds- normal vesicular breath sounds

trachea auscultation- bronchial breath sound 

no added sounds

vocal resonance present and uniform

Examination of other systems-

CVS

s1,s2 heard 

no murmurs heard no additional sounds

abdomen

no organomegaly

no shifting dullness

CNS

motor and sensory examination normal

reflexes present and normal

no muscle wasting

no loss in power

provisional diagnosis

upper respiratory tract infection with COPD (bronchiectasis)

AKI over CKD (resolving since 10 years)

investigations

Rx

nebulization - puolin 6th hourly

                    - bupescort 12th hourly

tablet azitromycin 500mg po/od/8am

syrup ascoryl ls po/t/d

monitor vitals every 4th hourly

optineuron iv 100ml ns/iv