THE WHITE ARMY
Respiratory case
Ritwik Pattnaik
Final Year
MBBS
Patient Details
Name: Mr XYZ
Age: 64 years
Sex: Male
Address: Chandrasekharpur, Bhubaneswar
Occupation: Retired Lecturer
Socioeconomic status: Upper Class
Informant: Self
DOA: 24/9/2021
DOE: 25/9/2021
Chief Complaints
Cough X 5 days
Fever X 5 days
Breathlessness X 3 days
History of presenting illness
Cough X 5 days
-Sudden onset
-Gradually progressive
-Associated moderate mucopurulent yellow sputum
-Non foul smelling sputum
-No hemoptysis
-No postural or diurnal variation
Fever X 5 days
-High grade
-Associated with chills and sweating
-Continuous
-Not relieved with over the counter antipyretics
-No myalgia, joint pain or rash
Breathlessness X 3 days
-Gradual onset
-Gradually progressive
-Breathlessness at rest, MMRC grade 4
-No postural or diurnal variation
-No orthopnea or paroxysmal nocturnal dyspnea
-No history of nasal congestion, sore throat or wheezing
-No histrionics of vomiting, diarrhoea, abdominal pain or dysuria
-No history of weight loss, hoarseness of voice or dysphagia
-No history of chest pain, orthopnea, PND, palpitations, syncope,
extremity edema or decreased urine output
-No history of altered mental sensorium.
Past History
-Diabetes mellitus X 10 years, on oral medication.
-No history of previous similar complaints, recurrent upper respiratory
tract infection, asthma, COPD or previous treatment for Tuberculosis.
-No history of stroke, seizure, near drowning, recent surgery or dental
procedure
-No history of hypertension or coronary artery disease
-No known allergies to drugs or environmental triggers.
Family History
-No history of similar complaints in family members
-No contact with patients of active tuberculosis
-No history of asthma,hay fever or eczema in family members.
Personal History
Diet: Balanced mixed diet
Appetite: Decreased since the onset of illness
Social: Retired lecturer
Monogamous relationship with his wife since last 40 years
Good living conditions, no pet, no recent travels
Addiction:10 cigarettes a day for 30 years
Whiskey on social occasions
Bowel and Bladder: Normal
Summary
A 64 year old diabetic male presented with complaints of cough with
Expertorcation for 5 days. He has a significant smoking history of 15
pack years.
Differential diagnosis
Lower respiratory tract infection - pneumonia
Acute hypersensitivity pneumonitis
Infective endocarditis
General Physical Examination
-The patient is conscious, cooperative and well oriented to time, place
and person.
-He is moderately built and moderately nourished.
Height: 175 cm
Weight: 70 kg
BMI: 22.9 kg/m2
-No external markers of tuberculosis
-No external markers of HIV.
-No pallor, icterus, clubbing, cyanosis, lymphadenopathy or edema
Vitals
Temperature: 101 F, oral
Pulse: 100 bpm, normal volume, regular rhythm, equally felt on both
sides with no radioradial or radiofemoral delay. Condition of the vessel
wall is normal. All peripheral pulses are palpable.
Blood Pressure: 100/70 mm hg measured in right upper arm in supine
position
Respiratory rate: 25/min, Thoracoabdominal, accessory muscles active
O2 saturation: 94% on room air
JVP: Not elevated
Local Examination
Upper Respiratory Examination
The external appearance of the ear and auditory canal is normal
The nose appears normal. Septum is central and there are no secretions.
The posterior pharyngeal wall is mildly erythematous.
There is no sinus tenderness.
INSPECTION
-Trachea is central in location.
-Apex beat is not seen
-Chest shape is normal
-Chest movements are reduced on right side with the use of accessory
muscles.
-Volume loss: There is no drooping of shoulders, crowding of ribs,
supraclavicular or infraclavicular hollowing, subcoastal or intercostal
retractions.
-Spine is cental with no kyphosis or scoliosis
-There are no scars, sinuses, visible pulsations or dilated veins over the
skin
PALPATION
-No tenderness or crepitus
-Trachea is confirmed to be central.
-Apex beat is palpated at the left fifth intercoastal space on the mid
clavicular line
-The AP diameter is 13 cm, horizontal diameter is 26 cm, AP to lateral
ratio is 1:2. Chest circumference is 60 cm. Total chest expansion is 4 cm
Expansion of right hemithorax is 1 cm, left hemithorax is 3 cm
-Vocal fremitus is increased over the right mammary and infra axillary
areas.
PERCUSSION
-Percussion over the clavicle produced a reasonant note
-There is dullness on percussion over the right mammary and the right
infra axillary areas compared to the corresponding lung areas of the left
side.
-Other areas have reasonant nodes
-Upper border of the liver was percussed at the right 5th intercoastal
space in the mid clavicular line
-Cardiac dullness was seen at the left of the sternum
AUSCULTATION
-Auscultation over the right mammary and infra axillary areas revealed
bronchial breath sounds, increased vocal reasonance, aegiphony and
whispering pectoriloquy.
-Coarse inspiratory crackles over the right infra axillary and infra scapular
areas.
-Normal vesicular breath sounds are auscultated in other bilateral lung
fields.
-Type and intensity: Bronchial breath sounds
-Adventitious sounds: Coarse inspiratory crackles
-Vocal reasonance: Increased, aegophony and whispering pectoriloquy
present.
Systemic Examination
GI EXAMINATION
Soft non tender abdomen. No organomegaly. No ascites
Cardiovascular system
S1 and S2 normal. No murmurs
Nervous system
Higher mental functions are normal. No focal neurological deficits.
Provisional Diagnosis
My provisional diagnosis for this patient is community acquired
pneumonia with a right middle to lower lobe consolidation and the
patient is in respiratory distress due to type 2 respiratory failure.
