Prefinal long case-83 yr old male with shortness of breath with pneumonia
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A 83yr old male came with complaints of shortness of breath since 15 days.
chief complaints:
Cough since 14 days
Fever since 12 days
shortness of breath since 15 days
History of Presenting illness:
Patient was admitted to ICU on 20/11/23 in the morning at 10 am with breathlessness. It was insidious in onset and gradually progressive, continuous and present during rest ( patient was feeling breathless even upon walking to washroom) with no associated relieving factors. Patient's attender also complained of awakening during night due to breathlessness. No h/o palpitations, stridor, or hoarseness of voice
Patients attender also told abt cough which was insidious in onset, gradually progressive associated with sputum which was white in colour ,scanty amount, mucoid in consistency and non foul smelling
Patient also complained of intermittent spikes of fever since 12 days( 4 times a day ), associated with chills and rigors, not relieved on taking medication and not associated with headache, vomiting
No h/o chest pain, orthopnea, PND
No h/o recurrent sore throat or cold
No h/o loss of consciousness,
PAST HISTORY:
No history of similar complaints in the past
Patient is N/K/C/O of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders
No h/o blood transfusions and surgeries
FAMILY HISTORY: Insignificant
PERSONAL HISTORY:
as mentioned by the attender
Diet - Mixed
Appetite - decreased
Sleep- Adequate
Bowel and Bladder movements- Regular
Addiction - consumption of alcohol occasionally,
h/o smoking since 30 yrs (3 packs per day) reduced to 1 pack per day since 2 yrs
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative and well oriented to time, place and person
He is moderately built
There is presence of pallor ,
pedal edema up to the knee
No cyanosis,
No clubbing
No lymphadenopathy
Vitals :
Temp - afebrile
BP - 120/70 mm hg measured on Left upper arm in supine position
Pulse rate - 120bpm , regular rhythm , normal character, high volume, no radio-radial and no radio-femoral delay
RR- 27cpm
SYSTEMIC EXAMINATION :
RESPIRATORY SYSTEM :
Upper respiratory tract :
Nose : no abnirmality detected
Oral cavity : whitish plaques like lesions distributed over the oral mucosa ( Oral candidiasis ?)
Examination of chest proper :
Inspection :
1. Shape of chest - elliptical
2. Trachea position-appears to be in central
3. Apical impulse - not seen
4. Movements of chest : abdominothoracic type of respiration, with indrawing of intercostal space.
5. Skin over chest : no redness ,engorged veins ,sinuses ,nodules ,scars and swellings.
6 . Abdominal quadrants moving equally with respiration
Palpation :
All inspectory findings are confirmed.
No local rise of temperature and tenderness
Percussion : Dull note in basal region
Auscultation :
1. Breath sounds- right side crepitations heard , prominent near basal region of lung and in infra axillary region- ( like water bubbles ?)
left side normal breath sounds
2. No other abnormal sounds heard
On admission - chest xray showing bilateral infiltrates with consolidation
CNS: No facial asymmetry.
No focal neurological abnormality detected
P/A : scaphoid, soft, non tender, bowel sounds heard and no organomegaly
On Admission :
Referral to psychiatry
Reports to have slept last night with sleep disturbance , 3times awakening due to SOB
Reports craving for tobacco
Rx- Tab olanzapine, clonazepam, nicotine gums
Provisional diagnosis: ARDS
Community acquired pneumonia- E.Coli
Tobacco and alcohol dependance syndrome
Lab investigations:
Advised -candid mouth plant l/A bd -2 weeks
Betadine gargle-3 times in a day
Bronchoscopy was done-white plague visualised near vocal cords and left pyriform fossa
Treatment given:
DNS,RL @75ml /hr
Inj.piptaz 4.5g iv 8 hrly
Tab.levofloxacin 750 mg po/od
Tab.bactrim-ds 800/160 po/bd
Cap.flucanazole 200mg po/od
Cap.doxycycline 100 mg po/bd
Inj pan 40 mg iv/od
Inj.neurobion forte 1 amp in 1000 ml ns
Syp.grillinctus 15ml po/tid
Neb.ipravent-8th hrly
Budecort-12th hrly
Tab-dolo 650mg po/tid
