patient with SOB

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A 70 year old female patient of resident nemani came to the opD with the chief complaint of shortness of breath since  evening

History of present illness :-  patient was apparently asymptomatic  4 Days back and developed Shortness of breath (grade 4), assosiated with fever, dry cough, throat pain, chestpain and constipation since 3 days 

History of past illness :- k/c/o hypertension since 6 yrs and on irregular medication 

N/k/c/o DM , asthma, epilepsy, tuberculosis, Lymphadenopathy 

 

Personal history :- 

 Diet :- mixed 

Apetite :- reduced 

Sleep :- adequate

Bowel and bladder movements :- irregular 

Addictions :- smoking , alcohol consumption occasionally - 10 yrs back 

Allergies :- No

Family history :- no history similar complaints in the family 

GENERAL EXAMINATION :- 

patient is conscious, non coherent

Weakly built, 

 Malnourished 

No pallor, cyanosis, icterus

No clubbing of fingers 

No lymphadenopathy 

Vitals :- 

Temp - febrile 

Pulse rate :- 84bpm 

Res. Rate :- BAE +

Fine crepts + infraaxillary 

     Wheeze + infraaxillary 

Bp :- 130/70mmhg

CVS :- S1S2 + 

CNS :- NAD 

Grbs :- 140 mg/dl

SYSTEMIC EXAMINATION :- 

CNS EXAMINATION :-

Patient is concious, non coherent, non coperative 

Cranial nerves :- intact 

CVS EXAMINATION :- 

S1S2 heard 

NO murmurs 

RESPIRATORY EXAMINATION :- 

INSPECTION :-

Chest is symmetrical 

Trachea shifted to left side 

 kyphoscoliosis 

No pulsations 

No drooping of shoulders

PALPATION :-  Trachea position deviated towards the left side 

Kyphoscoliosis is seen 

No dialated veins 

PERCUSSION :-

Dullness heard in left supraclavicular , infraclavicular, infraaxillary area

AUSCULTATION :- 

Breath sounds - normal 

Added sounds :- crepts and wheeze sounds are heard in infraaxillary region 

ABDOMEN EXAMINATION :- 

Shape of the abdomen :- scaphoid 

Tenderness :- No 

Free fluid :- No 

Liver :- not palpable 

Spleen :- not palpable 

PROVISIONAL DIAGNOSIS :- 

? Type 2 respiratory failure

? COPD 

INVESTIGATIONS :- 

ABG :- 

HEMOGRAM :- 

Chest x -ray :- 

ECG :- 

Treatment :- 

1. INJ PANTOP - 400 mg  (IV) - OD

2. INJ  AUGUMENTIN - 2gm (IV) -TID

3.INJ OPTINEURON - 1 ample 

4.HYDROCORT - 100 mg - BD

5.TAB DOLO - 650 mg