69yr/Fe with c/o hoarseness of voice since 10days, cough since 1 week, breathlessness since 3 days and fever since 1 day (long case)

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Chief Complaints:

        69year old female resident of Nalgonda, shopkeeper by occupation presented to casuality with chief Complaints:

Hoarseness of voice since 10 days.

cough since 1 week

breathlessness since 3 days  

fever (high grade) since 1 day, relieved on medication.

History of Present Illness:

         She was apparently asymptomatic 10 days ago, started complaining of noticeable change in her voice, hoarseness of voice which started gradually,not associated with foreign body sensation, difficulty in swallowing or any neck swelling 

Cough since 1 week, dry in nature(not associated with any expectoration),not associated with cold,sore throat,hemoptysis,loss of appetite or weight

Shortness of breath since 3 days of grade 1- MMRC which was aggravated on walking And relieved on Taking rest, it was not associated with wheeze,  pedal oedema, orthopnoea and PND.  Fever high grade associated with chills since 1 day, with no diurnal variation 

There was no h/o chest pain or tightness 

There was no history of pain abdomen, nausea, vomiting, loose stools, burning micturition.

History of Past illness:

       H/o similar complaints in the last, 2 years ago, which relieved on medication.

      No h/o TB

      Known case of Hypertension since 5 years on medication, Metaprolol xL-50mg OD, Amlodipine 5mg OD.

      Not a known case of DM, Asthma, Epilepsy, CAD, thyroid disorders.

      No h/o inhaler usage in the past.

          

Personal History:

     Married

     Shopkeeper by occupation

     Appetite: Normal

     Diet: Vegetarian

     Bowel movements: Regular

     Micturition: Normal

Family History:

      No member of the family has similar condition.

Menstrual History:

 Age of menarche:  16 years

No of days of cycle:  28days

Menopause: 15 years ago

Obstetric History:

Age of marriage: 18years

Age at first child birth: 18 years

Undergone permanent sterilisation.

General Examination:

Patient is moderately built and nourished.

Patient is conscious, coherent cooperatively oriented to time and place

No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalised Lymphadenopathy.

Vitals:

Temp:  103°

Respiratory rate:  29/min

Pulse:  113/min

Blood pressure:  120/70mmHg

Sp O2 : 88%

GRBS: 170mg%

Systemic Examination:

Respiratory system:

Position of trachea: 

Inspection:

 Upper respiratory tract examination:

 Nose- Right side nose hypertrophy

 Oral cavity- Normal oral hygiene.

Lower respiratory tract examination:

 Shape of chest- Barrell

 Trails sign 

 Supraclavicular hallow- positive

 Chest expansion- decreased movements 

 No crowding of ribs, drooping of shoulders, wasting of muscles.

 No usage of accessory muscles of respiration.

 Spinoscapular distance equal on both sides.

 Apical impulse not seen.

 No kyphosis/scoliosis 

 No sinuses, venous engorgements, visual pulsations.

Palpation:

 All inspectory findings are confirmed with palpation.

  Apex beat loacalised at Left 5th intercoastal space, 1 inch median to mid clavicular line

  Tactile Vocal Fremitus is equal on both sides 

  Antero-posterior diameter- 21cms

  Transverse- 22cms

   Cc I -  78cms

        E- 76cms

   Right hemithorax- 40cms

   Left hemithorax -38cms

Percussion:

                                  Right.                Left 

Supraclavicular.      Resonant.           R

Infra clavicular.       R.                        Dull

Mammary.                R.                        R

Axillary.                  R.                           R

Infra axillary.          R.                         R

Suprascapular.       R.                        R

Intrascapular.         R.                         R

Infra scapular.       R.                         R

                             Right.                         Left 

Supraclavicular. Normal vesicular.  NVBS

                             Breathe sounds 

Infra clavicular.  NVBS.                      NVBS

Mammary.           NVBS                    NVBS

Axillary.                 NVBS.                   NVBS

Infra axillary.        NVBS.                   NVBS

Suprascapular.     NVBS.                  NVBS.   

Intrascapular.       NVBS.                  NVBS

Infra scapular.      NVBS                  NVBS            

  Cardiovascular Examination:

Thrills: no

Cardiac sounds: S1, S2 heard

Cardiac murmurs: No

 Apex beat is found at 2cms medial to 5th intercoastal space

Provisional Diagnosis:

    Left upper lobe fibrosis? Secondary to TB with ?vocal cord palsy? Malignancy of larynx.

Hypertension since 5years on medication 

    Tab.Metaprolol xl 50mg OD

    Tab. Amlodipine 5mg OD

Investigation:

Treatment 

Inj.Augmentin 1.2mg IV

Tab.Azec 500mg OD

Inj.Neomol 10mg IV

Inj.Pantop 40mg IV

Tab.Paracetmol 650mg TID

Syrup.Grillinctus 2tbsp TID

Neb.Duolin 8 hourly

Nen.Mucomix 12 hourly