83 year old male with shortness of breath

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-> Chief complaints:

• Cough since 16 days

• Fever since 14 days

• Shortness of breath since 12 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 from grade 2 to grade 4, continuous and present during rest with no associated relieving factors. 

Patient's attender also complained of awakening during night due to breathlessness.

No h/o wheezing, stridor, or hoarseness of voice

Complained of 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 16 days, associated with chills and rigors. 

Not relieved on taking medication and not associated with headache, vomiting

No h/o chest pain, orthopnea, PND

-> 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:

• 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- 25cpm

-> 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 near base of the lungs 

    Left side normal breath sounds

2. No other abnormal sounds heard

CVS: S1, S2 heard , no murmurs 

CNS: No facial asymmetry. 

         No focal neurological abnormality detected

P/A : scaphoid, soft, non tender, bowel sounds heard and no organomegaly 

                            

-> Provisional diagnosis: 

? Community acquired pneumonia- E.Coli

-> Treatment:

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

QInj 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