65 year old female with cough since 4 months

 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

Cheif compliants:-

A 65 year old presented with 

1)cough since 4 months

2)Fever since 10 days 

Hopi:- 

Patient was apparently asymptomatic 4 months back then developed cough a/w sputum , which is whitish in colour, thick, moderate amount, more during nights.

H/o fever since 10 days, high grade a/w chills and rigor , internittent, no evening rise of temperature 

No h/o cold, SOB, chest pain, palpitations, excessive sweating, burning micturition, pedal edema, decreased urine output

H/o increased exposure to dust 

Past history :- 

similar complaints in the past 20 years ago , and a/w itching of eyes and relieved with inj. Dexamethasone 

K/c/o TYPE 2 DM since 10 years ( gulcoryl- m1 1/2 tab in the morning and half in the night )

N/k/c/o htn, tb, asthma, thyroid disorder, epilepsy 

Personal history:-

Oatient is moderately built and moderately nourished 

Diet: mixed 

Appetite: normal 

sleep: disturbed since last 10 days

Bowel and Bladder : regular bowel movements,  incresed frequency of urination during nights (5/night)

Addictions :- alcohol once in a month but stopped 1 year ago.

Tobbaco (chutta) since last 35 years daily one chutta 

General Physical Examination:-

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

Pallor is present 

Icterus,cyanosis, clubbing, lymphadenopathy and edema are absent.

vitals:-

Temp:- 97.2 ⁰F

BP:- 120/80 mmhg 

RR:- 20 cpm

PR :- 78bpm 

Grbs :- 173 mg%

Systemic examination:-

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space around 4 cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard.

There were no added sounds / murmurs. 

Respiratory system:

Bilateral air entry is present 

Normal vesicular breath sounds are heard.

Wheeze in the right supra scapular area.

Per Abdomen:

Shape is scaphoid

Abdomen is soft and non tender with no signs of organomegaly

Bowel sounds are heard

Hernial orifices are normal

A vertical surgical scar present from below umbilicus to the pubis symphisis

? Laparotomy i/v/o abdomianal mass 

CNS:

HMF- Normal

Memory- intact

Cranial Nerves :Normal

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Tone: Normal tone in upper and lower limb

Poweer: Normal power in upper and lower limb

Gait: Walks with a limp

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, 

 and ankle reflexes elicited.

Knee reflex  right ❌️   left ✅️

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited.

Provisional Diagnosis:-

LRTI ?PNEUMONIA .

Investigations:

ECG

CHEST X RAY

HEMOGRAM:- 

HB:-  10

TLC:- 11500

PCV:- 31.9

RBC:- 3.9

PLATELETS:- 3.5

CUE:- normal

PLBS:- 158 mg% on 3rd and 284 mg% on 4th

Blood urea:- 39 mg/dl

Serum creatinine:- 0.9 mg/dl

Serum electrolytes:- 

Na+ : 139 mEq/L

K+ : 4 mEq/L

Cl- : 102 mEq/L

 DIAGNOSIS:

? Community Acquired Pneumonia 

? Pulmonary TB with rt upper lobe consolidation

K/c/o type 2 DM since 5 years.

Treatment:-

Inj. AUGMENTIN 1.2 gm IV/BD for 5 days

Tab. AZITHROMYCIN PO/OD for 5 days

Tab. METFORMIN 500 mg + GLIMEPIRIDE 1mg PO/BD 1/2 tab