Conversations in October

7. On examination, he was a thin built elderly man sitting propped up at 45°. He was alert and conscious. GCS was 15/15. He was tachypneic with presence of pursed lips breathing, usage of accessory muscles for respiration - supraclavicular, suprasternal, intercostal and subcostal recession during inspiration. He was able to speak in phrases. He is on nasal prong with oxygen being delivered at a rate of 3L/minute. Peripheries were warm, hydration status was fair, capillary refill time was less than 2 seconds. There was no flapping tremor or palmar erythema. There was pallor noted on the conjunctiva. Otherwise, he was not cyanosed; there were no jaundice, digital clubbing or pedal oedema.
Anthropometric measurement: Weight: 53kg; Height: 165cm; BMI: 19.5
Vital signs: Respiratory rate: 30 breaths/minute; SPO2: 94% under facemask/ Blood pressure: 100/60mmHg / Pulse rate: 76 beats per minute, regular in rhythm, good volume and character. / Body temperature: 37.2°C

Examination of the throat: Unremarkable. No redness on pharyngeal wall. Tonsils not injected, no exudates seen.
Examination of the neck: Unremarkable. No cervical lymphadenopathy. JVP was 3cm – not raised. Thyroid examination was normal.

Respiratory system examination:
Inspection: There was presence of hyperinflation - increase in anteroposterior (AP) diameter to transverse diameter of the thorax. There is asymmetrical chest movement on respiration, with reduced chest wall movement on the right side. Otherwise there were no surgical scars or chest wall deformities seen on the chest.
Palpation: There was presence of trachea tug - reduced cricosternal distance. Trachea was shifted to the right side. There was reduced chest expansion on the right side.
Percussion: There was dullness over the right upper, middle and lower zone; resonant over left lung fields, with no loss of cardiac dullness.
Auscultation: There was unequal air entry into the lungs, with reduced air entry on the right side. Expiratory phase was prolonged in all lung fields. There were generalised rhonchi. There was presence of bronchial breath sounds and muffled vocal resonance over the right middle and lower zones of the lungs. There were also course end-inspiratory crackles over the right lower zone. There was no pleural rub heard.

Cardiovascular examination: Unremarkable. Apex beat is not deviated. It was felt at the left 5th intercostal space, located on the mid-clavicular line. There were no palpable thrills or parasternal heaving. Normal first and second heart sounds heard. There was no murmur.
Abdominal examination: Abdomen was flat, soft and non-tender. There was no organomegaly - liver, spleen and kidneys not palpable. No masses felt.

What abnormalities are you able to detect in this patient?
Is there anything that puzzles you about his vital signs?
What diagnoses will you explore in this patient?

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