Md.

Nazrul Islam, 62 years old, day labourer, normotensive, nondiabetic, smoker hailing from
Mithapukur, Rangpur admitted into RpMCH on 6 th February 2020 @ 6.30 PM with the complaints of
breathlessness for 1 year , cough for 6 months, right sided chest pain for 1 day.

According to the statement of the patient, he was reasonably well year back. Since then he has been
suffering from breathlessness which was gradual in onset, progressively increasing, aggravated on
exertion and relieved by taking rest and inhaler. But for last 1 day, he felt severe breathlessness which
was sudden in onset, more marked on lying to right side and lying flat and not relieved after taking rest
or inhaler. There is no history of PND.

Patient also complained of cough for 6 months. It is productive. Sputum is mucoid, not foul smelling, not
blood stained. Cough was present throughout day and night. Cough is aggravated during winter season.
There is no relation of cough with dust, pollen.

He also complained of right sided chest pain for 1 day which was sudden in onset, severe in intensity ,
sharp, stabbing in nature, aggravated by deep breathing, coughing and movement but there was no
radiation.

Patient also noticed loss of weight.

There is no history of trauma, fever, swelling of ankle. His bowel and bladder habit are normal.

The patient was admitted in the hospital 2 times with severe breathlessness in last 1 year and diagnosed
as a case of COPD.

For breathlessness he used to take some drugs and inhalers but he couldn’t mention the name.

No members of his family is suffering from such illness.

He is a smoker and smokes 20 pack year. He also chews betel nut.

He belongs to lower class family with poor sanitary facilities.

General physical examination:

Patient is emaciated, dyspnoeic with pursing of lips, body built is below average, cooperative. Patient
prefers to lie on left lateral and propped up position. Pulse is 124 bpm, BP 100/70 mm Hg., RR 32
breath/min, temperature normal. There is no anaemia, jaundice, cyanosis, clubbing, koilonyhia,
leuconychia, dehydration, edema, bony tenderness . There is no lymph node palpable in all accessory
areas, no thyromegaly. JVP is not raised. Skin condition normal.

Respiratory system examination:

Inspection:

1. Shape of the chest is barrel shape

2. Movement of chest restricted on right side of the chest

3. Intercostal spaces appear full

4. There is prominence of accessory muscles of respiration

5. Respiratory rate is 32 breath/min

6. There is no deformity, swelling, engorged vein, suprasternal recession and scar mark

Palpation:

1.Trachea—deviated to the left

2.Apex beat is situated in left 6th intercostal space in anterior axillary line, 12 cm from the midline ,
normal in character

3.Vocal fremitus—reduced in right side from 2 nd intercostal spaces to downwards along right
midclavicular line, from 5th intercostal space to downwards along right midaxillary line and from 6 th
intercostal space to downwards along right paravertebral and dorsal scapular line but normal on the left
side

4.Chest expansion—reduced on the right side of the chest.

Percussion:

1. Percussion note is Hyper-resonance in right side in previously mentioned areas but normal on
the left side
2. Upper border of the liver dullness—in the right 6th intercostal space in the midclavicular line.

Auscultation:

1.Breath sound—absent on the right side of the chest in previously mentioned areas , but
diminished vesicular with prolonged expiration on the left side.

2.Vocal resonance— absent on the right side of the chest in previously mentioned areas but
reduced on the left side.

Cardiovascular system:

1.Pulse is 124 bpm, rhythm is regular, volume is normal, character is catacrotic, radioradial and
radiofemoral delay is normal, condition of vessel wall is normal.

2.BP is 100/70 mm of Hg

3. JVP is not raised

4. Precordium:
On inspection of precordium reveals shape of precordium is normal, there is no visible pulsation, scar
mark, deformity, engorged vein or swelling

On palpation of precordium reveals Apex beat is situated in left 6th intercostal space in anterior
axillary line , 12 cm from the midline, normal in character; left parasternal heave, thrill and palpable
P2 are absent

On percussion area of superficial dullness is reduced

On auscultation of precordium 1st and 2nd heart sound are audible in all areas and normal in intensity.
There is no murmur and pericardial rub.

Examination of other systems reveals no abnormality

So my provisional diagnosis is COPD with Tension Pneumothorax.