lung collapse

Hello all this is G.Chaitanya , a eighth semester student.This E Log depicts the patient centered approach to learning

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 
CHIEF COMPLAINTS
 of cough and difficulty in breathing since 2 years, which aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive , initially it was MMRC grade I to MMRC grade IV 
No associated wheeze 
No orthopnea 
No seasonal variations, no pnd 
No history of recurrent upper/ lower respiratory tract infections 
Also complaints of cough since 2 years 
Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling
Not associated with blood
Cough aggravated on lying down
No seasonal variations 
No chest pain, palpitations, syncopal attacks 

PAST HISTORY 
K/C/O TB 30 years back, used medication for 4 months 
K/C/O HTN since 5 months 
N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY 
Diet mixed 
Appetite Normal 
Bowel and bladder movements regular
Sleep adequate 
Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION 
Patient is c/c/c , moderately built and nourished 
No pallor, icterus, cyanosis ,clubbing, lymphadenopathy, pedal edema 
Vitals:
Temp- afebrile 
PR- 78bpm
BP- 110/70 mmhg 
RR- 18cpm
SpO2- 97% at RA 


SYSTEMATIC EXAMINATION 
RESPIRATORY SYSTEM EXAMINATION 
URT
Oral cavity- hard palate , soft palate, uvula , tonsils , posterior pharyngeal wall - normal 
Dental caries present 
Nose - No septal deviation or Nasal polyps 

LRT
1.INSPECTION 
Shape of the chest - elliptical 
There is drooping of shoulder towards left side
Trachea appears to be central 
Equal movement of chest wall on both sides
No usage of accessory muscles 
No scars ,sinuses ,engorged veins, edema 

2.PALPATION 
No local rise of temperature , no tenderness 
Trachea deviated towards the left side
Movement of chest wall - slightly decreased on left side 
AP diameter is 22cm and Transverse diameter is 28 cm
Chest circumference -
On inspiration- 86.cm
On expiration - 86cm
Tactile fremitus - right left  
Supraclavicular increased 
Infraclavicular increased 
Mammary increased
Axillary increased 
Infra axillary increased
Suprascapular increased
Infrascapular increased
Interscapular increased

Vocal resonance -
                                   Right left 
  Supraclavicular Normal increased
  Infraclavicular Normal increased
  Mammary Normal increased 
  Axillary Normal increased 
  Infraaxillary Normal increased 
  Suprascapular Normal increased 
  Infrascapular Normal increased 
  Interscapular Normal increased 
  
3. PERCUSSION 
                                 Right left 
 Direct Normal decreased 
 Supraclavicular Normal decreased 
 Infraclavicular Normal decreased 
 Mammary Normal decreased 
 Axillary Normal decreased 
 Infra axillary Normal decreased 
 Suprascapular Normal decreased 
 Infrascapular Normal decreased 
 Interscapular Normal decreased

Investigations:

Hello all this is J. Mounika, a eighth semester student.This E Log depicts the patient centered approach to learning

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

80 year old male with  cough and difficulty in breathing since 2 years 

An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 
CHIEF COMPLAINTS of cough and difficulty in breathing since 2 years, which  aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive , initially it was MMRC grade I to MMRC grade IV 
No associated wheeze 
No orthopnea 
No seasonal variations, no pnd 
No history of recurrent upper/ lower respiratory tract infections 
Also complaints of cough since 2 years 
Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling
Not associated with blood
Cough aggravated on lying down
No seasonal variations 
No chest pain, palpitations, syncopal attacks 

PAST HISTORY 
K/C/O TB 30 years back, used medication for 4 months 
K/C/O HTN since 5 months 
N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY 
Diet mixed 
Appetite Normal 
Bowel and bladder movements regular
Sleep adequate 
Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION 
Patient is c/c/c , moderately built and nourished 
No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy, pedal edema 
Vitals:
Temp- afebrile 
PR- 78bpm
BP- 110/70 mmhg 
RR- 18cpm
SpO2- 97% at RA 


SYSTEMATIC EXAMINATION 
RESPIRATORY SYSTEM EXAMINATION 
URT
Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 
Dental caries present 
Nose - No septal deviation or Nasal polyps 

LRT
1.INSPECTION 
Shape of the chest - elliptical 
There is drooping of shoulder towards left side
Trachea appears to be central 
Equal movement of chest wall on both sides
No usage of  accessory muscles 
No scars ,sinuses ,engorged veins, edema 

2.PALPATION 
No local rise of temperature  , no tenderness 
Trachea deviated towards the left side
Movement of chest wall - slightly decreased on left side 
AP diameter is 22cm and Transverse diameter is 28 cm
Chest circumference -
On inspiration- 86.cm
On expiration - 86cm
Tactile fremitus -     right         left  
Supraclavicular                       increased 
Infraclavicular                          increased 
Mammary                                 increased
Axillary                                      increased 
Infra axillary                             increased
Suprascapular                          increased
Infrascapular                           increased
Interscapular                           increased

Vocal resonance -
                                   Right         left 
  Supraclavicular      Normal   increased
  Infraclavicular        Normal   increased
  Mammary               Normal   increased 
  Axillary                   Normal    increased 
  Infraaxillary            Normal    increased 
  Suprascapular       Normal    increased 
  Infrascapular         Normal    increased 
  Interscapular         Normal    increased 
  
3. PERCUSSION 
                                 Right       left 
 Direct                   Normal     decreased 
 Supraclavicular   Normal      decreased 
 Infraclavicular     Normal      decreased 
 Mammary            Normal      decreased 
 Axillary                Normal      decreased 
 Infra axillary        Normal      decreased 
 Suprascapular   Normal        decreased 
 Infrascapular     Normal        decreased 
 Interscapular     Normal        decreased

Investigations:




Provisional Diagnosis::-
LEFT COLLAPSE OF LUNG
k/c/o BRONCHIAL ASTHMA
k/c/o HYPERTENSION

Treatment::-

17/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID

18/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly IPRAVENT 6th hrsly

19/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly
- IPRAVENT 4th hrly

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