55 year old male with breathlessness since one week

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 CHIEF COMPLAINTS 

breathlessness exacerbated since one week 

Fever since 2 days .

HISTORY OF PRESENTING 

Patient complaints of breathlessness which has worsened from one week which is insidious in onset ,which was initially present on doing moderate heavy work and progressed to present stage of breathlessness even at rest .present throughout the day limiting his daily activities .

aggravates in cold weather ,and on exertion ,not associated with diurnal variation ,postural Variation ,initially relieved on using inhaler and history of use of nebuliser since one month present symptoms didn’t relieve with use of either ,associated with wheeze on exposure to cold . Associated with dry cough occasionally,insidious in onset not associated with blood tinged or foul smelling sputum 

Cough aggravates in cold weather ,no diurnal no postural varaiation ,cough during past were relieved over 6-7 days with no hospital admission 

MMRC grade 2 to MMRC 4 

Burning micturation since one day 

no history hemoptyisis ,chest pain ,recurrent infection ,rhinitis /sinusitis ,fever ,TB contact 

Orthopnea ,swelling of legs ,PND 

Sudden loss of weight ,dysphagia ,hoarseness of voice 

Joint pain ,skin rashes ,numbness of extremities 

Present symptoms subsided on admission to hospital and on receiving treatment with Oxygen .

PAST HISTORY 

similar complaints of breathlessness since 3 years ,for which he using inhaler ,nebuliser since one month .

No K/C/O TB,DM,HTN seizures ,thyroid abnormalities,pneumonia , recurrent LRTIs ,heart disease ,bleeding or clotting disorders 

NO SURGICAL HISTORY 

NO KNOWN ALLERGIES .

FAMILY HISTORY 

No similar complaints in the family 

No history of TB ,pneumonia , asthma ,heart diseases ,HTN in family 

PERSONAL HISTORY 

55 year old male toddy tapper by occupation,married father three daughters ,

Consumes mixed diet 

Decreased appetite since one week 

Disturbed sleep since one week 

Bowel and bladder regular 

Chronic smoker - stopped smoking 5 years back 

Used to smoke 20 cigarettes per day 

consumes alcohol everyday whiskey 90ml 

GENERAL PHYSICAL EXAMINATION 

Patient is conscious ,cohrent ,co operative 

He is well built and well nourished.

No signs of pallor,icterus,cyanosis, clubbing,lymphadenopathy,edema.

Vitals 

Temperature:afebrile 

Blood pressure:120/80 mm Hg

Respiratory rate :16cpm with oxygen

Pulse rate:75bpm

Systemic examination:

respiratory system 

Inspection: 

No structural abnormalities in nose, no obstruction in nasal airway .

Oral cavity - no crooked teeth

No ulcers in mouth.

Post pharyngeal wall is normal 

No post nasal discharge 

Trachea appears to be central.

Chest is Bilateral symmetrical.

Elliptical in shape.

Symmetrical expansion on both sides.

No scars ,sinuses,engorged veins.

Palpation:

No local rise of temperature

No tenderness.

Trachea is central.

Anterioposterior diameter - 19 cm .

Transverse diameter -28 cm .

Apex beat present in medical to mid clavicular line in 5th intercostal space.

Chest expansion equal on both sides.

Tactile vocal fremitus bilaterally equally resonant  on both sides.

Percussion.

supraclavicular 

Infraclavicular 

mammary 

axillary 

Infraxillary 

Suprascapular 

Infrascapular 

Interscapular 

AUSCULTATION 

vesicular breath sounds were heard on both sides with added breath sounds 

supraclavicular  rhonchi are heard in areas of upper and middle lobes  

Infraclavicular  decreased breath sounds 

mammary decreased breath sounds 

axillary          decreased breath sounds 

Infraxillary decreased breath sounds 

Suprascapular decreased breath sounds 

Infrascapular decreased breath sounds 

Interscapular decreased breath sounds 

Per abdomen examination: 

On inspection

Shape of abdomen : flat

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation 

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion 

Resonance note heard

On auscultation 

Bowel sounds heard 

CVS examination:

S1 S2 heard 

No murmurs heard 

CNS examination :

No focal neurological deficits found.

PROVISIONAL DIAGNOSIS 

respiratory pathology probably acute exacerbation  of copd

Anatomical generalised inv of both the lungs 

pathology chronic obstructive pathology of airways and alveoli 

Risk factor smoking and age