A 69 year old female c/o of shortness of breathe and weakness since 2 days, fever(high grade) since 2 days hoarseness of voice since 10 days and cough since 1 week

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Chief complaints -

69year old female resident of Nalgonda came to the OPD with chief Complaints of shortness of breath and weakness since 2 days,

fever(high grade) since 2 days 

hoarseness of voice since 10 days and 

cough since 1 week 

History of Present Illness:

She was apparently asymptomatic 10 days ago, then started complaining of horseness of voice which began gradually

Cough since 1 week, dry in nature

Shortness of breath since 3 days (grade 1)

Fever high grade associated with chills since 1 day

History of Past illness:

       H/o similar complaints in the last, 2 years ago, which relieved on medication.

      No h/o TB

   Known case of Hypertension since 5 years

Not a known case of DM, Asthma, Epilepsy,thyroid disorders. 

      No h/o inhaler usage in the past.

Personal History:

     Daily routine- She used to wake up around 6am,have breakfast around 9am and then used to go to the shop. She used to have lunch at 1pm and would take rest for sometime and have dinner around 8pm.

     Appetite: Normal

     Diet: Vegetarian 

     Bowel movements: Regular

     Micturition: Normal

Family History:

      No significant family history 

General Examination:

Patient is conscious, coherent cooperative and well oriented to time and place.

No signs of Pallor, Icterus, Cyanosis, Clubbing or 

Generalised Lymphadenopathy.

Vitals:

Temp:  102 F

RR:  28/min

PR:  110/min

BP:  115/70mmHg

Sp O2 : 88%

GRBS: 160mg

Systemic Examination:

Respiratory system:

Position of trachea: central

Inspection:

 

 Shape of chest- Barrel shape

 Trachea central in position 

 Supraclavicular hallow- positive

 Chest expansion- decreased movements 

 Spinoscapular distance equal on both sides.

 No kyphosis/scoliosis 

 No sinuses, venous engorgements.

Palpation:

 All inspectory findings are confirmed with palpation.

  Apex beat - 2 cm medial to mid clavicular line

  Tactile Vocal Fremitus is increased in left infraclavicular area

  Antero-posterior diameter- 21cms

  Transverse- 22cms

  

   

Percussion:

Tactile Vocal Fremitus is increased in left infraclavicular area

                                 Right.             Left

Supraclavicular     Resonant.        R

Infraclavicular.         R.                  Dull

Mammary.               R.                   R

Axillary.                     R                  R

Infra axillary.            R                   R

Suprascapular.        R                   R

Interscapular.          R                   R

Infrascapular           R                   R

Auscultation:

                                 Right.                 Left

Supraclavicular.  Normal vesicular   NVBS

                              breathe sounds

Infraclavicular.    NVBS.                      Tubular

Mammary.           NVBS                        NVBS

Axillary.                NVBS.                      NVBS

Infra axillary.       NVBS.                      NVBS

Suprascapular.    NVBS.                      NVBS

Interscapular.      NVBS.                     NVBS

Infrascapular       NVBS.                    NVBS

  

Cardiovascular Examination:

Thrills: no

Cardiac sounds: S1, S2 heard

Cardiac murmurs: No

 Apex beat is found at 2cms medial to 5th intercoastal space. 

CNS:- 

Memory intact 

Higher mental functions normal

Oral examination - dental caries on left lower molar is present 

 

Provisional Diagnosis:

  We might suspect  Left upper lobe fibrosis or vocal cord palsy or maybe Malignancy of larynx.

Hypertension since 5years.

Treatment :

Inj.Augmentin 1.2mg IV

Tab.Azec 500mg OD

Inj.Neomol 10mg IV

Inj.Pantop 40mg IV

Tab.Paracetmol 650mg TID

Syrup.Grillinctus 2tbsp TID

Neb.Duolin 8 hourly