80 YR OLD MALE WITH COUGJ AND DIFFICULTY IN BREATHING.

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

80p year old male with  cough and difficulty in breathing since 2 years 

An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 
CHIEF COMPLAINTS of cough and difficulty in breathing since 2 years, which  aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive . 

No associated wheeze 
No orthopnea 
No seasonal variations, no pnd 
No history of recurrent upper/ lower respiratory tract infections 
Also complaints of cough since 2 years 
Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling
Not associated with blood
Cough aggravated on lying down
No seasonal variations 
No chest pain, palpitations, syncopal attacks 

PAST HISTORY 
K/C/O TB 30 years back, used medication for 4 months 
K/C/O HTN since 5 months 
N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY 
Diet mixed 
Appetite Normal 
Bowel and bladder movements regular
Sleep adequate 
Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION :
Patient is c/c/c , moderately built and nourished 
No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy, pedal edema 
Vitals:
Temp- afebrile 
PR- 78bpm
BP- 110/70 mmhg 
RR- 18cpm
SpO2- 97% at RA 


SYSTEMATIC EXAMINATION 
RESPIRATORY SYSTEM EXAMINATION

Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 
Dental caries present. 
URT
Nose - No septal deviation or Nasal polyps 

LRT
1.INSPECTION 
Shape of the chest - elliptical 
There is drooping of shoulder towards left side
Trachea appears to be central 
Equal movement of chest wall on both sides
No usage of  accessory muscles 
No scars ,sinuses ,engorged veins, edema 

2.PALPATION 
No local rise of temperature  , no tenderness 
Trachea deviated towards the left side
Movement of chest wall - slightly decreased on left side 
AP diameter is 22cm and Transverse diameter is 28 cm
Chest circumference -
On inspiration- 86.cm
On expiration - 86cm

Tactile fremitus -     right                       left  
Supraclavicular     normal             increased 
Infraclavicular      normal             increased 
Mammary              normal             increased
Axillary                 normal             increased 
Infra axillary      normal                        increased
Suprascapular      normal                   increased
Infrascapular        normal                   increased
Interscapular          normal                 increased

Vocal resonance -
                                   Right         left 
  Supraclavicular      Normal   increased
  Infraclavicular        Normal   increased
  Mammary               Normal   increased 
  Axillary                   Normal    increased 
  Infraaxillary            Normal    increased 
  Suprascapular       Normal    increased 
  Infrascapular         Normal    increased 
  Interscapular         Normal    increased 
  
3. PERCUSSION 
                                 Right       left 
 Direct                   Normal     decreased 
 Supraclavicular   Normal      decreased 
 Infraclavicular     Normal      decreased 
 Mammary            Normal      decreased 
 Axillary                Normal      decreased 
 Infra axillary        Normal      decreased 
 Suprascapular   Normal        decreased 
 Infrascapular     Normal        decreased 
 Interscapular     Normal        decreased
INVESTIGATIONS
Chest x- ray
Serological tests
RANDOM BLOOD SUGAR
ECG
HEMOGRAM
LFT
SERUM ELECTROLYTE
RFT

Provisional diagnosis:
LEFT COLLAPSE OF LUNG
k/c/o BRONCHIAL ASTHMA
k/c/o HYPERTENSION

Treatment:

17/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID

18/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly IPRAVENT 6th hrsly

19/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly IPRAVENT 4th hrsly

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