62 year old female suffering from fever, cough, breathlessness

Note : This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

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I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

Name: Keerthi M

Roll no: 165

Case scenario: A 62 year old female who is a field worker by profession has complaints of

Fever since 10 days
Cough since 10 days
Breathlessness, which started with the fever

History of present illness:

Patient was apparently asymptomatic and then developed a fever of high grade, continuous type, associated with chills and rigours, which was relieved on taking medication.
She also developed dry cough, which started with the fever and is episodic in nature; happening once in every 3 hours
Along with the cough, she also developed shortness of breath; which she experiences every two hours

History of past illness: Not significant

Personal history:

Marital life - married
Occupation - field worker
Appetite - reduced
Diet - mixed
Bowel movements - regular
Micturition - regular
Sleep - regular
Known allergies - none
Habits/addictions - consumption of betel leaves around 3 times a day since 30 years

Family history: not significant

PHYSICAL EXAMINATION

A. General

Pallor - No
Icterus - No
Cyanosis - No
Clubbing of toes/fingers - No
Lymphadenopathy - No
Oedema of feet - No
Malnutrition - No
Dehydration - No
Pulse rate - 83 beats/min
Respiratory rate - 16 breaths/min
Blood pressure - 110/70 mmHg
SpO2 at room air -95 %
GRBS -106 mg/dL
No birth deformities seen

B. Cardiovascular system

Thrills - No
Cardiac sounds - S1,S2
Cardiac murmurs - none
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No precordial bulge
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs

C. Respiratory system

Dyspnoea - No
Wheeze - No
Position of trachea - General
Respiratory sounds - Vestibular
No abnormal sounds detected
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant
On auscultation :
• Bilateral air entry was present, normal vesicular breath sounds were heard.
• Vocal resonance: resonant in all areas