A 83yr old male came with complaints of shortness of breath
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A 83yr old male came with complaints of shortness of breath
chief complaints:
cough since 14 days
shortness of breath since 10 days
History of Presenting illness:
Patient was admitted to ICU on 20/11/23 in the morning at 10 am with breathlessness. It was insidious in onset and gradually progressive, continuous and present during rest ( patient was feeling breathless even upon walking to washroom) with no associated relieving factors. Patient's attender also complained of awakening during night due to breathlessness. No h/o palpitations, stridor, or hoarseness of voice
Patient also complained of cough which was insidious in onset, gradually progressive associated with sputum which was white in colour ,scanty amount, mucoid in consistency and non foul smelling
Patient also complained of intermittent spikes of fever since 12 days( 4 times a day ), associated with chills and rigors, not relieved on taking medication and not associated with headache, vomiting
No h/o chest pain, orthopnea, PND
No h/o recurrent sore throat or cold
No h/o loss of consciousness,
PAST HISTORY:
No history of similar complaints in the past
Patient is N/K/C/O of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders
No h/o blood transfusions and surgeries
FAMILY HISTORY: Insignificant
PERSONAL HISTORY:
History of progressive weight loss since 6 months as mentioned by the attender
Diet - Mixed
Appetite - decreased
Sleep- Adequate
Bowel and Bladder movements- Regular
Addiction - consumption of alcohol occasionally,
h/o smoking since 30 yrs (3 packs per day) reduced to 1 pack per day since 2 yrs
GENERAL EXAMINATION :
Patient is unconscious.
He is moderately built
There is presence of pallor ,
pedal edema up to the knee
No cyanosis,
clubbing present ?
No lymphadenopathy
Vitals :
Temp - afebrile
BP - 120/70 mm hg measured on Left upper arm in supine position
Pulse rate - 120bpm , regular rhythm , normal character, high volume, no radio-radial and no radio-femoral delay
RR- 27cpm
SYSTEMIC EXAMINATION :
RESPIRATORY SYSTEM :
Upper respiratory tract :
Nose : normal anatomy of nose
Oral cavity : whitish plaques like lesions distributed over the oral mucosa ( Oral candidiasis ?)
Examination of chest proper :
Inspection :
1. Shape of chest - funnel shaped
2. Trachea position- central
3. Apical impulse - not seen
4. Movements of chest : abdominothoracic type of respiration, with chest retractions( accessory muscles involved )
5. Skin over chest : no redness ,engorged veins ,sinuses ,nodules ,scars and swellings.
6 . Abdominal quadrants move synchronously with respiration
7. Trails sign negative
Palpation :
All inspectory findings are confirmed.
No local rise of temperature and tenderness
Dimensions of chest :
Anterioposterior less than transverse diameter
Tactile vocal fremitus- palpable crepts
Percussion : Right hemithorax- Dull note
Left hemithorax- resonant,
Auscultation :
1. Breath sounds- right side crepitations heard , prominent over lower lobe- ( like water bubbles ?)
left side normal breath sounds
2. No other abnormal sounds heard
3. Vocal resonance - decreased on all areas
CVS: S1, S2 heard , no murmurs
CNS: No facial asymmetry.
No focal neurological abnormality detected
P/A : scaphoid, soft, non tender, bowel sounds heard and no organomegaly
Treatment :
Advised -candid mouth plant l/A bd -2 weeks
Betadine gargle-3 times in a day
Bronchoscopy was done-white plague visualised near vocal cords and left pyriform fossa
Treatment given: DNS,RL @75ml /hr
Inj.piptaz 4.5g iv 8 hrly
Tab.levofloxacin 750 mg po/od
Tab.bactrim-ds 800/160 po/bd
Cap.flucanazole 200mg po/od
Cap.doxycycline 100 mg po/bd
Inj pan 40 mg iv/od
Inj.neurobion forte 1 amp in 1000 ml ns
Syp.grillinctus 15ml po/tid
Neb.ipravent-8th hrly
Budecort-12th hrly
Tab-dolo 650mg po/tid
Fever chart monitoring 1/12/23
OSCE questions:
1.What are fine crackles and coarse crackles and in which conditions do you hear them?
Crackles are discontinuous sounds, resembling the sound produced by rubbing strands of hair together in front of the ear or by pulling apart strips of Velcro. There are coarse crackles, which are loud, low pitched, and fewer in number per breath, and fine crackles, which are soft, higher pitched, and greater in number per breath.
Fine crackles are heard with pulmonary edema, pulmonary fibrosis, and pneumonia; they are predominantly inspiratory.Coarse crackles are usually heard at the beginning of expiration and are characteristic of bronchiectasis.
2.Difference between bronchial and vesicular breath sounds.?
Bronchial breathing is the breath sound heard over the tracheobronchial tree. Bronchial breath sounds are loud, harsh breath sounds with midrange pitch and intensity. These sounds typically emanate from the larynx, trachea, and bronchi. The expiratory sound is longer than the inspiratory sound. Vesicular breathing is soft, low pitched, rustling in quality, while bronchial breathing is loud, harsh breath sounds with midrange pitch and intensity.
Bronchial breathing anywhere other than over the trachea, right clavicle or right interscapular space is abnormal. Presence of bronchial breathing would suggest:
• Consolidation
• Cavitation
• Complete alveolar atelectasis with patent airways
• Mass interposed between chest wall and large airways
• Tension Pneumothorax
• Massive pleural effusion with complete atelectasis of lung
https://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/b-sounds.htm
3.Etiopathogenesis of pneumonia.
The most frequently isolated microorganisms were P. aeruginosa (n=9, 18%) and methicillin-resistant Staphylococcus aureus (MRSA; n=8, 16%). Positive blood cultures with agents considered as causative of pneumonia were found in six patients (Klebsiella oxytoca, Enterobacter aerogenes, P. aeruginosa, Escherichia coli, Enterobacter cloacae and MRSA). Aetiological diagnosis of pleural empyema was achieved in three of five cases, and the causative agents were MRSA in two cases and coinfection of Streptococcus milleri and E. coli in another case. Four patients with negative serum Aspergillus antigen had Aspergillus fumigatus isolated in association with a Gram-negative strain and were not considered pathogenic. One patient submitted to surgical resection of lung aspergiloma developed a postoperative pneumonia with no other microorganism isolated besides Aspergillus, had a positive serum Aspergillus antigen, and therefore the fungus was considered the causative agent. Legionella urinary antigen was performed in 49% of patients, without any positive results.
https://www.nhlbi.nih.gov/health/pneumonia
4. What sounds are typically heard in this case?
Gurgling sounds heard during tidal breathing or speech, or auscultated over the larynx, are strongly associated with HAP. In very ill patients, gurgling is usually associated with severe debilitation or death. “Death rattle is a term applied to dying patients to describe the noise produced by the oscillatory movements of secretions in the upper airways.
https://www.sciencedirect.com/science/article/abs/pii/S00123692106040845. Further management of this case and role of ECMO (extra corporeal membrane oxygenation).
Traditionally, lung failure is treated with mechanical ventilation, also called a breathing machine. These machines use positive pressure to push more air into the lungs and facilitate gas exchange, thus providing needed oxygen and removing carbon dioxide. The problem is that humans breathe naturally with a negative pressure breathing mechanism, so normally, when we inhale, the pressure in our lungs is negative, so breathing machines work the opposite of our normal breathing. For people who are very sick, this increase in positive pressure can strain the lungs by increasing the volume and pressure of air being inhaled, which in turn can cause lung injury. ECMO works because it allows the lungs to rest and it allows us to minimize the harm that the breathing machine causes.
ECMO pulls your blood outside of the body from one large vein, puts it through a pump which then pushes the blood through a membrane lung that facilitates gas exchange externally. It then returns your oxygenated blood to your body via another large vein through a tube that's positioned close to the right side of the heart. The ECMO machine performs the function of the lungs successfully so the lungs can rest and we can use very low settings on the breathing machine. This protects the lungs from additional damage that the high pressures from the breathing machine cause.
https://erj.ersjournals.com/content/22/6/876
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