Prefinal -83 year old male with shortness of breath with pnemonia

This is an a 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.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.

A 83yr old male came with complaints of  

cough since 20 days

Fever since 19 days

Shortness of breath 17 days 

History of Presenting illness:

Patient was admitted to ICU on 20/11/23 in the morning at 10 am with  breathlessness. It was insidious in onset and gradually progressive, continuous and present during rest ( patient  was feeling breathless even upon walking to washroom) with no associated relieving factors. Patient's attender also complained of awakening during night due to breathlessness. No h/o palpitations, stridor, or hoarseness of voice 

Patients attender also told abt   cough which was insidious in onset, gradually progressive associated with sputum which was white in colour ,scanty  amount, mucoid in consistency and non foul smelling

 Patient also complained of intermittent spikes of fever  since 19 days( 4 times a day ), associated with chills and rigors, not relieved on taking medication and not associated with headache, vomiting

 No h/o chest pain, orthopnea

No h/o recurrent sore throat or cold

No h/o loss of consciousness, 

PAST HISTORY:

No history of similar complaints in the past

Patient is N/K/C/O of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders

No h/o blood transfusions and surgeries

FAMILY HISTORY: Insignificant

PERSONAL HISTORY

as mentioned by the attender

Diet - Mixed

Appetite - decreased

Sleep- Adequate

Bowel and Bladder movements- Regular

Addiction - consumption of alcohol occasionally,

h/o smoking since 30 yrs (3 packs per day) reduced to 1 pack per day since 2 yrs

GENERAL EXAMINATION :

Patient is conscious, coherent and cooperative.

He is moderately built

There is presence of pallor ,

pedal edema up to the knee

No cyanosis, 

No clubbing

No lymphadenopathy

Vitals : 

Temp - afebrile

BP - 120/70 mm hg  measured on Left upper arm in supine position

Pulse rate - 120bpm , regular rhythm , normal character, high volume, no radio-radial and no radio-femoral delay

RR- 27cpm

SYSTEMIC EXAMINATION :

 RESPIRATORY SYSTEM :

Upper respiratory tract :

Nose : no abnirmality detected

Oral cavity : whitish plaques  like lesions distributed over  the oral mucosa ( Oral candidiasis ?)

Examination of chest proper :

Inspection : 

1. Shape of chest - elliptical

2.  Trachea position-appears to be in central

3. Apical impulse - not seen

4. Movements of chest : abdominothoracic type of respiration, with indrawing of intercostal space.

5. Skin over chest : no redness ,engorged veins ,sinuses ,nodules ,scars and swellings.

6 . Abdominal quadrants moving equally with respiration

Palpation :

All inspectory findings are confirmed.

No local rise of temperature and tenderness 

Percussion :  Dull note  in basal region

 Auscultation :

1. Breath sounds- right side crepitations heard , prominent near basal region  of lung and in infra axillary region- ( like water bubbles ?)

    left side normal breath sounds

2. No other abnormal sounds heard

On admission - chest xray showing bilateral infiltrates with consolidation

            After he developed ARDS

CVS: S1, S2 heard , no murmurs 

CNS: No facial asymmetry. 

No focal neurological abnormality detected

P/A : scaphoid, soft, non tender, bowel sounds heard and no organomegaly 

 On Admission :

Referral to psychiatry

Reports to have slept last night with sleep disturbance , 3times awakening due to SOB

Reports craving for tobacco

Rx- Tab olanzapine, clonazepam, nicotine gums

Provisional diagnosis: ARDS

? Community acquired pneumonia- E.Coli

Tobacco and alcohol dependance syndrome

Lab investigations: 

Treatment  :

Advised -candid mouth plant l/A bd -2 weeks

Betadine gargle-3 times in a day

Treatment given: DNS,RL @75ml /hr

Inj.piptaz 4.5g iv 8 hrly

Tab.levofloxacin 750 mg po/od

Tab.bactrim-ds 800/160 po/bd

Cap.flucanazole 200mg po/od

Cap.doxycycline 100 mg po/bd

Inj pan 40 mg iv/od

Inj.neurobion forte 1 amp in 1000 ml ns

Syp.grillinctus 15ml po/tid

Neb.ipravent-8th hrly

Budecort-12th hrly

Tab-dolo 650mg po/tid