1801006025 long case

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A 60year old female came to the opd with the 

CHIEF COMPLIANT:

1.cough with sputum since 10days

2.breathlessness since 10days

HOPI:

patient was apparently asymptomatic 10days back,then she has developed cough with expectoration which is insidious in onset, gradually progressive and associated with whitish colour, mucoid,non foul smelling,non blood stained 

Aggravates on lying on left side and during night times 

 Breathless of grade 2 mmrc(i.e walk slower than other people of same age due to shortness of breath) since 10days

Which is associated with wheeze

H/o low grade fever with chills and rigor which is on and off since 10days which relieved by medications 

H/o of weight loss, burning micturation 

No h/o night sweats(r/o tb)

No h/o orthopnea,pnd ,chest pain , palpitations

No h/o lower limb swelling, reduced urine output, change in voice 

No h/o seasonal variation of above symptoms

PAST HISTORY:

h/o similar complaints in the past 5year back which relieved by medications

H/o diabetes mellitus past 6year on medication (metformin)

No h/o a known tb case,asthma,htn, epilepsy, thyroid

PERSONAL HISTORY

diet-mixed diet

Appetite -normal

Sleep -adequate

No addiction

Bowel and bladder -regular:

Daily routine:she usually wakes at 6am and do her daily morning activities and have her breakfast and go for work(selling businesses)and return back at night 7pm and have dinner and sleep bt 8pmnight but from past 4months due to leg pains she stopped working and now her daily routine is she wakes at 6am and do her morning activities and do small house hold workes and rest whole day and sleep by 8pm.

GENERAL EXAMINATION

patient was conscious, cooperative and oriented to time,place and person

Well nourished and moderately built

No pallor

No icterus 

No cyanosis 

No clubbing

No pedal edema

No lymphadenopathy

External marker of tb-choroid tubercles,phlycten,scars/sinuses,cold abscess/collar stud abscess absent

No external marker of malignancy 

Vitals-

Temperature -99°F

Pulse rate -100/min

Respiratory rate -22/min

Bp-120/80 mm Hg

Spo2-97%

Grbs -307 mg%

Respiratory system examination:

Upper respiratory tract:

Nostrils -normal 

No Dns,nasal polyps,sinus tenderness 

Oral cavity -normal

Oral hygiene is maintained 

No dental caries 

Posterior pharyngeal wall - normal

LRT:

Inspection:

Shape of chest- normal(bl symmetrical , elliptical)

Spine normal 

Trachea appear to be central

Chest movement equal on both sides 

Pattern of breathing -thoraco abdominal 

No usage of accessory muscles

No dropping of shoulder 

Skin over the chest normal 

No scars ,sinuses ,visible pulsation

Palpation:

All inspectory finding are confirmed

Spine normal

Trachea central

Apex beat palpable at 5th intercoastal space ,1cm medial to mid clavicular line

No local rise of temperature

No tenderness 

Tactile vocal fremitus normal all over the areas 

Dimensions of measurement

Transverse diameter -12inches

Anterior posterior diameter -10.5inches

Td:ap diameter -1.14

Chest circumference -87cms

Percussion

Areas.              Right.               Left

Supraclavicular resonant Resonant 

Clavicular resonant Resonant 

Infraclavicular resonant Resonant 

Mammary resonant Resonant 

Axillary  resonant Resonant 

Infraaxillary resonant Resonant 

Suprascapular resonant Resonant 

Interscapular resonant Resonant 

Infrascapular resonant Resonant 

AUSCULTATION

Areas.              Right.              Left

Supraclavicular normal normal

Infraclavicular normal normal

Mammary. Normal.     Normal

Axillary.     Normal. Normal

Infraaxillary.  Mid inspiratory crepts heard.    normal(left)

Suprascapular normal normal

Interscapular normal normal

Infrascapular mid inspiratory coarse crepts (right and left)

Vocal resonance -normal over all areas

Cvs - s1,s2 normally heard ,no murmur

Jvp not raised

Cns-consious orientation ,no focal neurological deficit

Sensory system normal

Cranial nerves intact

Motor system normal

PA- soft ,non tender,no organomegaly,normal bowel sound heard

Diagnosis 

Right sided bronchiectasis associated with diabetic melitus

Investigation:

CBP-

Hb-11.7 gm/dl

Total leucocytosis-16,200cells/cumm

Platelet count- 3.98lakhs/cu.mm

Smear-normocytic normochromic with leucocytosis 

Glycated hb-hbA1c -7%

Urine for ketone bodies absent 

Complete urine examination -normal

Serum creatinine level-normal

Serum electrolyte level -normal

Liver function test -normal 

C reactive protein -postive on 9/3/23

Negative -11/03/23

HBsag -negative

Hiv -negative 

Chest x ray

CT scan

Ecg

sputum 

Treatment:

Inj.augmentin 1.2gm iv tid

Inj.pantop 40mg iv od 

T.Pcm 650mg po

Syp.Ascoril po tid 2tsp

T.glimipride 1mg +metformin 500mg bd

Syp.citralka 10ml in 1glass of water bd

Normal saline compressor

T.MVT

T.shelcal 500mg po od

Chest physiotherapy 

Neb with mucomist 8th hrly &ipravent 6th hrly

O2 inhalation if spo2<94%

Diabetic diet