64 yr old male with lower respiratory tract infection

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A 68YR OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF COUGH  AND HEADACHE  since 1 week

History of present illness::

Patient was apparently asymptomatic 1 week ago then he developed COUGH initially dry later progressively expectoration started white in colour moderate quantity ,non foul smelling,not blood stained, no nocturnal and diurnal variation , relieved on medication with SOB grade 3 with fever since 4 days low grade ,sore throat present.

H/o polyuria and polydypsia since 1 week.

No H/o wheez, chest pain, palpitations.

H/o loss of appetite since 1 day.

Headache in parietal region,full aching type not with photophobia,phonophobia.

No h/o vomiting,abdominal pain,constipation,loose stool,giddiness ,blurring of vision.

PAST HISTORY :

-k /c/ o  HTN  since 5 yrs and on amlong 10.

-No h/o DM,Thyroid , TB , Asthma  Epilepsy , CVA .

Family history : not significant .

PERSONAL HISTORY : 

Diet - mixed 

Appetite - reduced since 1day

Bowel movements - regular, bladder - regular 

Sleep - adequate 

Addictions : consumes alcohol occasionally since 10 yrsyy.

- No smoking 

- No allergies   

GENERAL EXAMINATION :

- Patient was examined after taking his consent 

- Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished 

- No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy .

Vitals..

Pulse:80bpm

Bp:140/80 mm of hg

Temperature::afebrile

RR:16c/min

Systemic examination

Respiratory examination

Inspection-

B/L symmetrical and elliptical

Trachea appears to be central

No supraclavicular and infraclavicular hallowing present

Expansion of chest equal on both sides

Expansion of chest normal

No crowding of ribs 

No drooping of shoulder

No Wasting of muscles present

No scoliosis ,kyphosis

No sinuses,scars,engorged veins

Palpation-

No local rise of temperature

All inspectory findings confirmed

Trachea central 

Apex beat felt in 5th ICS in mid clavicular line

Percussion-

Direct : over clavicle and manubrium sternum

Indirect :

                                  Right.       Left.

Supraclavicular. Resonant. Resonant

Infraclavicular. Resonant. Resonanat

Mammary. Resonant. Resonant

Inframammary. Resonant. Resonanat

Axillary Resonant. Resonant

Infraaxillary. Resonant Resonant

Suprascapular. Resonant. Resonant

Interscapular. Resonant Resonant

Infrascapular. Resonant. Resonant

Auscultation-

 B/L air entry present

Normal vesicular breath sounds heard

CVS- 

S1 S2 heard,no murmurs present.

Per Abdomen :

 soft , Non tender , bowel sounds + , 

no signs of organomegaly 

CNS :

higher mental functions : normal 

MOTOR-: normal tone and power 

reflexes:

             RT           L  T

Biceps ++           ++

Triceps ++          ++

Supinator ++       ++

Knee ++              ++

Ankle ++             ++

Investigations:

RFT:

Provisional diagnosis:

Lower respiratory tract infection?