1801006026-short case.

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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. 

A 67 year old male resident of peddaoora  Carpenter by occupation Came with the cheif complaints of short ness of breath  since 4 years and cough since 3 years  

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 4 years ago then he developed shortness of breath, insidious in onset,gradually progressive ,progressed from grade 1 to 2( MMRC) ,shortness of breath is more after smoking

no orthopnea,no PND, no pedal edema

No h/o seasonal and diurnal variations

Cough since 3years,dry cough ,more after smoking , no seasonal and diurnal variation 

No h/o fever,chest pain,vomitings, Palpitations. 

PAST HISTORY:

Not a known case of Diabetes mellitus ,Hypertension,Tuberculosis,Epilepsy,Asthma.

FAMILY HISTORY:

not relevant 

PERSONAL HISTORY:

Diet:mixed 

Appetite:decreased 

Sleep :Adequate 

Bowel and bladder :Regular.

Addictions:Patient is a chronic smoker since 30 years .

He used to smoke bidi 20 years back 10 bidis per day and since 10 years he is smoking cigarettes 10 per day.

DAILY ROUTINE :

He is Carpenter as well as farmer by occupation 

He daily wakes at 6Am and goes to bathroom 

Fresh up and baths and drinks tea at 7 am and he smokes 1 cigarette after tea and goes to agriculture field and does work there up to 10 am

And in the mean time he smokes 2 cigarettes .

And at 10 am he again comes home and have his breakfast (which may include idly ,dosa,upma etc.) And after breakfast he again smokes 1 cigarette and then goes to agriculture field works till 12 pm and in the mean time he smokes 1 cigarettes. And he reach home at  

12pm and takes nap up to 1 pm and wakes at 1pm and have his lunch which consists of rice and a vegetable curry .and smokes 1 cigarette then he start doing his Carpenter work like making tabels 

And ploughs (nagali) and some other stuff and works till 6pm and in the mean time he smoke

3 to 4 cigarettes and at 6 pm he stops his works and takes bath and he watch TV till 8 pm and have his dinner at 8pm smokes 1 cigarette and then sleeps at 9 pm.

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

Moderately built and nourished. 

Patient has clubbing which is of  grade 2

No Pallor ,icterus,cyanosis,lymphadenopathy and edema . 

Vitals:Temp:afebrile 

Pulse rate :86 bpm

Respiratory rate:16 cpm Regular ,thoracoabdominal.

Bp:110/70mmHg 

SYSTEMIC EXAMINATION:

Examination of Respiratory system:

INSPECTION :

Upper Respiratory tract inspection:

No Halitosis

Good oral hygiene. 

oral thrush absent.

No postnasal drip .

No deviated nasal septum

No nasal polyps.

Lower Respiratory tract inspection:

Chest is symmetrical

Trachea :midline  

Drooping of shoulders absent.

No intercoastal retraction 

Patient have PECTUS EXCAVATUM.

No scars ,sinuses ,no dilated veins.

Movement with respiration symmetrical on both sides .

Accessory muscles are not used while respiration. 

PALPATION:

All inspectory findings are confirmed. 

Trachea midline.

Chest movements symmetrical on both sides .

Measurement of chest expansions: form 90 cm in inspiration to 93 cm in expiration

Tactile Vocal fremitus:All areas on Right side and left side are normal .

PERCUSSION:                      right             left 

Clavicular  percussion   resonant       Resonant

Infraclavicular                 Resonant      resonant

Mammary area               Resonant      resonant

Inframammary area       Resonant      Resonant

Axillary area.                   Resonant.      Resonant 

Suprascapular.               Resonant.        Resonant 

Interscapular.                 Resonant.        Resonant 

Infrascapular.                 Resonant.       Resonant 

AUSCULTATION:

Breath sounds : Normal vesicular breathsounds .

Added sounds:crepts heard on infrascapular area.

Vocal resonance:all areas on the left and right side are resonant.

CVS EXAMINATION:

S1 S2 HEARD,NO murmurs 

CNS EXAMINATION:

No focal neurological deficits.

PERABDOMEN:

Soft ,non tender 

No organomegaly present .

Clinical images :

Investigations:

Cxr..

 

Provisional diagnosis: copd??

Chronic bronchitis??