CASE DISCUSSION- 80 year old Male with Lower back pain, cough and shortness of breath
RACHANA GANGULA
ROLL NO 110
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80 YEAR OLD MALE PATIENT WITH LOWER BACK PAIN, COUGH AND SHORTNESS OF BREATH
A 80 year old male patient resident of Bhongir, who was an agricultural worker until 4 years ago and is now unemployed, presented to the OPD on 16/11/21 with chief complaints of
- shortness of breath since 20 days
- cough since 20 days and
- lower back pain since 10 days.
Patient was apparently asymptomatic 20 days back, then he developed productive cough.
Sputum was white in color, non blood stained, non-foul smelling. No diurnal variation in sputum production was noticed.
Cough was sudden in onset. No progression. Aggrevated on lying down and walking. Relieved on using medication given by local RMP.
Fever with chills and rigor for 3 days before admission
Loose stools on Day 2 of admission, 3 episodes in a period of 6hours- watery in consistency
Nausea present, since past 10 days.
This was associated with shortness of breath which was initially Grade IV but it subsided on treatment with medication from another hospital.
Patient started the treatment around 10 days ago.
Patient complains of bilateral lower Back pain since the past 10 days.
Type of pain- squeezing pain
No aggrevating or relieving factors
Not progressive
Not Radiating
Patient is unable to walk without support because of the lower back pain.
PAST HISTORY
Patient has joint pains in both knee joints and wrist joints since the past 10 years and has been using analgesic medication given by local RMP- 1 tablet every two days since the past 10 years.
Patient has itching throughout the body since the past 1 year and has been using a lotion to control the itching, prescribed by local RMP everyday before taking a bath since the past 1 year.
Patient lost sight in the right eye around 50 years ago from a household accident. He was gathering and beating firewood to kindle a fire in his household and during that process. It was associated with bleeding from the eye and subsequent loss of vision in the entire right eye.
Not a known case of Diabetes Mellitus, Hypertension, epilepsy, tuberculosis.
PERSONAL HISTORY
Patient consumes a mixed diet.
Sleep is adequate, until 20 days ago when he was not able to sleep well because of the SOB. He is able to sleep well after starting medication 10 days ago.
Bowel and bladder movements are regular until day 2 of admission.
Addictions-
Smoked bidi (5 per day) for 15 years. Stopped 20 years ago
Drinks Toddy everyday since past 50 years. (500ml/day)
No Allergies
GENERAL EXAMINATION
Patient is concious, coherent, cooperative and well oriented to time and place.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Edema- absent
Vitals-
BP- 110/70 mmHg
Pulse- 65bpm
Respiratory Rate- 14 cpm
Temperature- afebrile
RESPIRATORY EXAMINATION
INSPECTION-
Shape of chest- elliptical in shape
Symmetry- symmterical on both sides, no unilateral bulge
Subcostal angle- 90°
No retractions, scars or sinuses
Trachea- midline
Prominent LEFT STERNOCLEIDOMASTOID
No visible apical impulse
Trail sign -ve
Respiratory movements- symmterical movements of chest on inspiration and expiration are seen.
( Prominent carotid pulsation in Carotid Triangle)
PALPATION-
Normal tracheal length
No tracheal shift
Apical Impulse- 5th ICS on midclavicular line
PERCUSSION
AUSCULATION
INVESTIGATIONS
5 days before admission -HOSP 1
HRCT THORAX
5 days before admission- HOSP 1
CRP- ELEVATED- 182 mg/dL
day of admission- HOSP2
BIOCHEMICAL INVESTIGATIONS
day of admission- HOSP2
RADIOLOGICAL INVESTIGATIONS
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