A 70 year old male with cough, SOB and chest pain.

April 25, 2023

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A 70 year old male, labourer by occupation, came to casualty with chief complaints of cough since 5 days, shortness of breath since 5 days and chest pain since 5 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days back and then he developed cough which was sudden in onset, continuous and gradually progressive. It is dry cough which was more in the night. It was associated with vomitings which was only during the intake of water. It was dark orange in colour, 3 episodes per day, non projectile and not associated with any nausea or giddiness. There are no associated sympotoms with cough like cold, sore throat, PND, sinusitis, acid reflux, hoarseness, stridor, nightsweats, weight loss. Patient also developed shortness of breath, sudden in onset which was sudden in onset, grade 4 (MMRC grading), no orthopnea or nocturnal dyspnea. No aggravating or relieving factors. Patient also had chest pain, sudden in onset, gradually progressive, diffuse type, which is of dragging type, radiating to back from down to upwards. It aggravates while breathing and coughing and no relieving factors. It was not associated with any palpitations, chest tightness, wheezing, body ache, night sweats, fever, myalgia and headache.

PAST HISTORY:

There are no similar complaints seen in the past. Patient is a known case of Diabetes mellitus since 1 year and is taking sitagliptin. Patient is also a known case of hypertension and is on Telma 40. Patient had a surgery for an abdominal lump 30 years ago. Patient had allergic reactions one year back over his chest area for which he took soap powder recommended by his nearby doctor. Patient has no history of CVD, epilepsy, TB, asthma, thyroid disorders.

FAMILY HISTORY:

No similar complaints seen in the family.P

PRSONAL HISTORY:

Diet is mixed, appetite decreased, sleep is inadequate, bowel and bladder movements are regular. No addictions. No known allergies.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Thin built and poorly nourished.

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

temp: afebrile BP: 100/60mmHg PR: 86bpm RR:17cpm SpO2:95%

SYSTEMIC EXAMINATION:

Respiratory system:

upper respiratory tract: white coated tongue- anterior 2/3rd. improper denture. uvula is central, external framework normal Anterior DNS to left mucosa is pale. laryngeal framework normal. laryngeal crepitus +

Lower respiratory tract:

On Inspection, shape of chest is symmetrical, elliptical, no scoliokyphosis present. A vertical scar above umbilicus and scar on either flanks are present. Scars due to allergic reaction all over his chest are present. Chest movements are symmetrical. No intercostal recession. Trachea appears to be central. No dilated veins, visible pulsations, sinuses. No drooping of shoulders. No crowding of ribs. Right supraclavicular hollowing is seen. Abdomino-thoracic type of respiration.

On Palpation, all inspectory findings are confirmed. No local rise of temperature. No tenderness. Trachea is central. No crowding of ribs. No intercostal tenderness. Chest movements on left side are reduced. AP diameter: 16cm transverse diameter: 27cm. Vocal fremitus is normal on supraclavicular, infroclavicular, mammary, axillary, infraaxillary, suprascapular, interscapular and infrascapular. Apex beat felt at 5th ICS medial to the mid clavicular line.

On Percussion, vocal fremitus is dull on the (left 6thICS), left mammary, infrascapular and infra axillary, resonant on the other areas. Vocal fremitus is normal on the right side.No liver dullness. No shifting dullness present.

On Auscultation, fine crepts are heard during expiration on left mammary, infrascapular and infra axillary. normal on the other areas. Right side is normal. NVBS are heard. Vocal resonance: hypo resonant notes are heard at left mammary, infrascapular and infra