Respiratory System
HISTORY:
Particulars:
• Name: Jitendra Jaiswal
• Age :41 years
• Sex: Male
• Residence:Titwala, Mumbai
• Occupation: Salesman
• Religion: Hindu
• Belongs to lower middle socioeconomic class according to Modified Kuppuswamy Scale
Date of admission: 18/8/2021
Date of examination: 23/8/2021
Chief complaints:
• Right sided chest pain since 2 weeks
• Breathlessness on exertion since 2 weeks
• Cough with expectoration since 2 weeks
• Fever since 2 weeks
History of presenting illness:
1. The patient was apparently well 2 weeks back when he developed right sided chest pain in the
infraclavicular and mammary areas which was:
• Acute in onset
• Sharp and catching in character
• Not associated with radiation or positional variation
• Non-progressive
• Aggravated by coughing and deep inspiration • Associated with fever and breathlessness
• Not relieved by medication
2. He also complained of difficulty in breathing since 2 weeks.
• The breathlessness was acute in onset.
• The patient felt breathless while walking up a flight of stairs.
• Non-progressive.
• Not associated with wheezing.
• Not associated with sleep disturbance
3. Patient also gives history of cough since 2 weeks:
• Acute in onset
• Associated with expectoration of greenish black thick sputum with foul odor, 30-40ml/day
• Non-progressive
• Not associated with diurnal or positional variations
• Not associated with blood in sputum
• Not associated with increase after exposure to smoke/dust/cold.
• Not relieved by cough syrups.
NEGATIVE HISTORY:
• No h/o Paroxysmal Nocturnal Dyspnea
• No h/o orthopnea/platypnea/trepopnea
• No h/o hemoptysis
• No h/o hoarseness of voice
• No h/o palpitations or syncope
• No h/o abdominal distension
• No h/o altered sensorium
• No h/o recurrent infections
• No h/o change in appetite or weight loss
• No h/o similar episodes in the past
The above complaints were also associated with fever since 2 weeks:
• Acute in onset
• High grade (documented: 104-106 °F)
• 2-3 spikes per day, usually during night
• Associated with chills and rigors
• Not associated with altered mental status, rash, neck stiffness or joint pain
• Temporarily relieved by medication.
PAST HISTORY:
• H/o previous appendicectomy in 2010.
• H/o malaria in 2012.
• No h/o DM, HTN, Hypo/hyperthyroidism.
• No h/o of Koch’s or Koch’s contacin
• No h/o of any chronic drug exposure.
PERSONAL HISTORY:
• Smokes 2-3 cigarettes /day since 10 years = 2-3 pack years.
• Occasionally consumes alcohol once or twice a month
• No change in bowel & bladder habit
• No h/o change in appetite.
• Normal sleep-wake cycle.
FAMILY HISTORY:
• Married
• 2 children: 12 y/o daughter, 6 y/o son, healthy.
• Mother (66 y/o) has Diabetes mellitus since 10 years
• No h/o malignancy in the family.
Education history: 12th pass
SUMMARY:
41 year old male patient presented with right sided chest pain, productive cough, breathlessness on
exertion (Grade I MMRC) and high grade fever with chills and rigors since 2 weeks, with no history of any
significant illness in the past. These symptoms suggest involvement of the Respiratory system, probably
parenchymal.
DIFFERENTIAL DIAGNOSES:
• Empyema
• Consolidation
• Lung abscess
• Pleural effusion
• Hydro pneumothorax
EXAMINATION:
The patient is conscious and cooperative, oriented to time, place and person.
He has an average built and is moderately nourished.
Height: 163cm, weight: 62 kg, BMI: 23.3 kg/m²
Examined with consent.
VITALS:
• Pulse: 79 beats/min, regular rhythm, adequate volume, normal character, no radio radial or
radio-femoral delay, no vessel thickening, no apex-beat deficit, all peripheral pulses were well
felt.
• Respiratory rate: 20 cycles per minute, abdominothoracic
• Blood pressure: 116/74 mmHg, measured in right brachial artery in supine position
• Temperature: 98.4 °F
• JVP: Not raised
GENERAL PHYSICAL EXAMINATION:
• Pallor: absent
• Icterus: absent
• Cyanosis: absent
• Clubbing: increased fluctuation in the nail bed, better appreciated in the index finger (Grade 1
clubbing)
• Lymphadenopathy: absent
• Edema: absent
SYSTEMIC EXAMINATION:
Examination of the upper respiratory tract:
• Examination of nose, paranasal sinuses and oral cavity was normal.
• No evidence of leukoplakia, erythroplakia, dental caries or nicotine stains.
• Larynx could not be examined.
Examination of the Lower Respiratory Tract:
1. Inspection:
• Trachea: central.
• Shape of the chest: normal.
• Movements: bilaterally equal, slightly decreased.
• Apical impulse: visible, apparently in normal position.
• Respiration: 20 breaths/min, normal rhythm and depth, abdominothoracic pattern, no use of
accessory muscles, no intercostal retractions.
• ICD present in right infra-axillary region.
• No erythema, scars, swellings, sinuses or dilated veins sseen
• Back: normal lumbar lordosis. Kyphoscoliosis, drooping of shoulders, winging of scapula and
gibbus absent.
2. Palpation
• Afebrile to touch.
• Trachea: central in location
• Crico-sternal distance: 3 finger breadths.
• Diffuse tenderness in the right infraclavicular and mammary areas.
• Localized tenderness in the right infra-axillary area.
• Respiratory movement bilaterally equal and decreased as observed during chest expansion.
• Apex beat felt in left 5th intercostal space 2cm medial to midclavicular line.
• Tactile fremitus, friction fremitus, subcutaneous emphysema, rib crowding/ widening absent.
3. Measurements:
• AP diameter: 20cm
• Transverse diameter: 29cm
• Chest expansion: 4cm
• Right hemithorax expansion: 1.5cm (45.5cm – 44cm)
• Left hemithorax expansion: 2.5cm (46.5cm – 44cm)
• Spinoscapular distance:
-Right : 12cm
-Left : 12cm
• Spinoacromial distance:
-Right : 14cm
-Left : 14cm
4. Vocal fremitus
5. Percussion
6. Auscultation
7. Vocal resonance
Bronchophony, aegophony and whispering pectoriloquy present on R Side.
OTHER SYSTEMS:
1. CVS:
• Precordium appears normal
• S1, S2 heard normally
• Apex impulse in left 5th intercostal space 2cm medial to mid-clavicular line
• No murmurs detected
2. CNS: NAD
3. Abdomen:
• Soft, non-tender
• No organomegaly
SUMMARY:
41 year old male patient presented with right sided chest pain, productive cough, breathlessness on
exertion (Grade I MMRC) and high grade fever with chills and rigors since 2 weeks, with no history of any
significant illness in the past.
The patient was averagely built and moderately nourished with a pulse rate of 79 beats per min,
respiratory rate of 20 cycles per min, blood pressure of 130/86 mmHg & temperature 98.4 °F.
On RS examination, respiratory movements were bilaterally equal but slightly decreased. TVF and VR
increased on the right infraclavicular, mammary, axillary, interscapular and infrascapular areas. On
percussion, woody dull note was noted in the previously mentioned spaces. On auscultation, tubular
bronchial breath sounds were heard in the same areas. Bronchophony, aegophony and whispering
pectoriloquy were also present.
Other system examinations were within normal limits.
DIAGNOSIS:
Right middle & lower lobe consolidation.
Etiology: community acquired pneumonia
Not in respiratory failure or cor pulmonale.
