A 55yr old male with sob

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Case:A 55 yr old male toddy tree climber by occupation came to OPD with cheif complaints of  

sob at rest since 2 days

High grade fever since 2 days

Dry cough since 1day

HopI:

Patient was apparently asymptomatic 

3yrs ago then he developed sob( grade -1)mmrc which is insidious in onset,non progressive till 10/4/23

Aggrevated on exposure to cold weather and dust relieved on medication and on rest

Not associated with orthopnea and pnd

On 10/4/23 patient developed sob( grade -4) which is sudden  in onset ,non progressive associated with wheeze 

No aggrevating and relieving factor 

H/o High grade fever since 2days sudden in onset, intermittent,not associated with chills and rigors and relieved on medication

H/o dry cough since 1day

No H/o chest pain, haemoptysis 

Past history:

He has no similar complaints in the past. Not a k/c/o diabetes, hypertension

No history of blood transfusion.

PERSONAL HISTORY:

 

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder regular

FAMILY HISTORY

No significant family history

General examination

Pallor: absent 

Icterus: absent 

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

Vitals:

Temp: afebrile on time of examination 

BP 120/90

Heart rate 90 bpm

Resp Rate 18 cpm 

Spo2-94on o2

Respiratory examination

Inspection :

Shape of the chest -round

Trachea appears to be central

Usage of accessory muscles -present

No dropping of shoulders

No crowding of ribs. 

Apex impulse is not observed 

Palpation 

No local rise of temperature

No tenderness

Trachea -central

Chest movements -equal on both sides

Ap diameter-28cm

Transverse diameter -32cm

Chest circumference:

Inspiration:87cm

Expiration :85cm

Chest expansion:2cm

Percussion: 

                    Rt.                                  Lt

SCA.             Resonant.                 Resonant

ICA.                R.                              R

MA.               R.                              Dull

IMA.             Dull.                          Dull

AA.               R.                                R

IAA.               R.                            R

SSA.              R.                             R

ISA.              R.                              R

Infra SA.      R.                            R

Auscultation : bilateral rhonchi are heard in MA,IAA,ISA,inter SA

CVS:

S1,S2 are heard

No murmurs

Per Abdomen:

Shape is scaphoid

Abdomen is soft and non tender with no signs of organomegaly

Bowel sounds are heard

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Investigations:LFT

TB:0.54mg/dl

DB:0.2mg/dl

ALT:247IU/l

ALP:176IU/l

Hb:12.6gm/dl

TLC:11,000

Plt count:2.4lakhs

Provisional diagnosis:excerbation of copd, type 1 respiratory failure 

Rx

O2inhalation with face mask 4-6lit/min to maintain spo2-95

Syp.grillincitus tid

Inj.piptaz 4-5gm IV tid

Pantop 40mg- bbf

T.shelcal od

Lidiliv 300mg bd

Inj hydrocort 100mg 2hrs after meal