1601006005 (SHORT CASE)

 

1601006005 (SHORT CASE)

This is an E log book to discuss our patient de- identified health data shared after taking his/her consent 



A 51 year old male patient resident of Miryalguda, farmer by occupation, presented with  chief complaints of  

1. Fever since 10 days 

2. Cough with sputum since 10 days 

3. Shortness of breath since 7 days 



History of present illness:

Patient was apparently asymptomatic 10 days back then developed following symptoms 

Fever which was insidious in onset and it was associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication 

He then developed Expectorate Cough which gradually progressed more during the nights followed a similar diurnal pattern . It aggrevated during exposure to colder climates .The sputum was scanty and yellow which was non foul smelling

Cough was associated with Chest pain which was non radiating in nature and aggrevated on lying down relieved on sitting upright 

He later developed gradually Dyspnea which went on to interfere his daily activities (indicating MMRC Grade 3 / 4 ) and eventually progressed to orthopnea 

No history of wheeze 



Past history 

No history of:

Asthma 

Diabetes Mellitus 

Hypertension 

Epilepsy 

COPD : 6 yrs 

TB : 5 yrs back

Family history - Not relevant 

Personal history:

Sleep: disturbed due to SOB

Bowel and Bladder - Regular

Appetite - Normal

Diet - Mixed 

No food or drug allergies 

Addictions - Smoking since 40 yrs (3 to 4 cigarettes a day)
Smoking index - 120 
Alcohol since 40 yrs  

DIFFERENTIAL DIAGNOSIS:

Pneumonia 

TB

COPD 



GENERAL EXAMINATION: 

Patient was conscious coherent and cooperative 

Seems to be undernourished 

Vitals 

Pulse - 82 bpm
Regular
Normal volume 
BP - 100/70 mm hg
Respiratory rate - 29 cpm 

On physical examination:

Pallor - absent

Icterus - absent 

Cynosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - absent 



SYSTEMIC EXAMINATION: 

RESPIRATORY: 

Upper respiratory tract examination:

Nostrils : Normal
Nasal septum: No deviated nasal septum
Nasal polyps: No nasal polyps
Tonsils : No enlarged tonsils
Posterior pharyngeal wall appears to be normal


INSPECTION:

Shape and symmetry : Elliptical and symmetrical 
Spine: Central
Trachea : Appears to be central






Respiratory movements decreased on both sides
Breathing pattern was Thoracoabdominal

No visible pulsations 

No visible scars or sinuses

PALPATION:

Spine is central

Trachea is central



Dimensions:  AP 16.5 cm
                       Transverse 23.5 cm





Chest expansion was equal on both the sides

Vocal fremitus was increased on left infra clavicular and mammary region

Apex beat was felt on 5 th intercostal space medial to MCL

PERCUSSION: 

On percussion dull note was heard on 

Left infra clavicular
Left mammary 
Left infra scapular

AUSCULTATION:

Tubular breath sounds 

There was an Increased vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)

Crepitation were felt on left infra axillary region

CVS:  

Normal S1 S2 heard 

No murmurs

Apex beat felt on 5 th intercoastal space 

CNS:

No focal deficits seen

PROVISIONAL DIAGNOSIS::
Left Upper lobe consolidation

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