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


 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


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







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