85/F with SOB
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LFT:-
Hemogram
On 18/08/23
On 19/08/23
pleural fluid - ADA
On 21/08/23
On 22/08/23
On 23/08/23
A 85 F housewife resident of choutuppal came to the OPD with
Chief complaints -
Difficulty in breathing -10 days
HISTORY OF PRESENTING ILLNESS :-
patient was apparently asymptomatic 10 days ago then she complained of shortness of breath which progressed from grade 3- grade 4 according to MMRC.
Aggravated by physical activity.
She has a history of fall 30 days back and sustained injury to right hip for which she was taken to a hospital and was admitted there for 5 days and was diagnosed with right intertrochanteric fracture and received symptomatic treatment and was sent to home for bed rest . After which she developed generalized weakness as the patient's food intake was reduced and later she developed bed sores in the right gluteal region .
No history of fever, cold, burning micturition , chestpain , palpitations, decreased urine output, pedal edema .
Past history :-
She is not a known case of HTN ,DM ,CVA ,CAD ,TB ,ASTHMA.
Personal history:-
Diet :- mixed
Appetite:- decreased
Bowel and bladder:- normal and regular
Sleep:- adequate
Tobacco chewer 1/ day for 30 years
Family history:-
Not significant
General examination:-
Patient is conscious and disoriented
Pallor present
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Edema
Vitals :-
Temperature:- afebrile
Pulse rate :- 120
Bp:- 120/70
Respiratory rate :- 24 cpm
Spo2:- 96 at room air
Systemic examination
Respiratory:-
Inspection:-
Chest is bilaterally symmetrical
Trachea – midline in position
Apical Impulse is not appreciated .
No dilated vein ,scars and sinuses
Palpation :-
All inspectory findings are confirmed
Trachea is central in position.
Apex beat not appreciable
Reduced bilateral chest movements are present.
Percussion :-
Dull note was heard over left axillary and infra axillary areas .
Auscultation:-
Bilateral air entry - present
Vesicular breath sounds heard
Bilaterally decreased breath sounds.
Cardiovascular system:-
•Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
•S1 and S2 heard , no added thrills and murmurs heard.
Per abdomen:-
INSPECTION
Shape of abdomen appears to be Normal
No Visible epigatric veins
No engorged veins sinus scars
PALPATION
All inspectory findings conformed
Abdomen soft & Non tender
No organomegaly
PERCUSSION
Tympanic note heard all quadrants abdomen
AUSCULTATION
Bowel sounds heard.
CNS examination :-
No focal neruological deficit.
Investigations:-
On 16/08/23
Hemogram :
RFT:-
On 17/08/23
D-dimer
ABG
CUE
Serum electrolytes
Pleural (sugar,protein)
On 20/08/23
Provisional diagnosis:-
?Pulmonary emobolism
?Emphysema.
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