80M WITH LUNG COLLAPSE

Hello all this is G Pranay kumar rao,a eighth semester student.This E Log depicts the patient centered approach to learning

This is an 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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

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 , initially it was MMRC grade I to MMRC grade IV 
-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 
URT
Oral cavity- hard palate , soft palate, uvula , tonsils , posterior pharyngeal wall - normal 
Dental caries -present 
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                 increased 
Infraclavicular                   increased 
Mammary                          increased
Axillary                              increased 
Infra axillary                      increased
Suprascapular                  increased
Infrascapular                    increased
Interscapular                     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:-
ECG:-
DOPPLER 2D ECHO:-


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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