1601006015 SHORT CASE

 

1601006015- GM Final Short Case


51-Year-Old Male Patient  Farmer by occupation resident of Miryalaguda .

He came up with a chief complaint: 
1. Fever and cough with sputum from 10 days 
2. Shortness of breath from 7 days

History of present illness

The patient was apparently asymptomatic 10 days back, then developed the following symptoms

Fever 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 Cough with sputum which gradually progressed more during nights followed a similar diurnal pattern. It aggravated 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 aggravated on lying down, relieved on sitting upright.

He later developed gradually Dyspnea which went on to interfere with his daily activities (indicating MMRC Grade 3).

Past History:

No history of Asthma, Diabetes Mellitus, Hypertension, and Epilepsy.
TB: 5 Years back and treated with Anti tubercular drugs.

Family History:

Not relevant

Personal History:

Sleep: inadequate
Bowel and bladder movements: regular
Appetite: Normal
Diet: Mixed
No food or drug allergies
Addictions: 
Smoking from 40 years (3 to 4 cigars/day)    (Smoking Index: 120)
Pack years:6

Differential Diagnosis

Pneumonia
TB
COPD

Examination

The patient was conscious, coherent, and  co-operative
Seems to be undernourished

Vitals

Pulse:    82 bpm  |  Regular  |  Normal Volume
BP: 100/70 mm of Hg
Respiratory Rate: 30 cycles per min

On Physical Examination
  • Pallor absent
  • Icterus absent
  • Cyanosis absent
  • Clubbing absent
  • Lymphadenopathy absent
  • Edema absent

Systematic Examination:

Respiratory
Upper respiratory tract examination
  • Nostrils: Normal
  • Nasal septum: No deviated nasal septum
  • Nasal polyps: No nasal polyps
  • Tonsils: No enlarged tonsils
  • The posterior pharyngeal wall appears to be normal

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






Respiratory movements decreased on both sides
Breathing pattern normal
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 decreased
Vocal fremitus was increased on the left infraclavicular and mammary regions.
Apex beat was felt on 5th intercostal space medical to MCL.

Percussion
On percussion dull note was heard on
  • Left infraclavicular
  • Left mammary
  • Left infrascapular
Auscultation

Tubular(bronchial)breath sounds heard.
There was an increased vocal resonance on the left infraclavicular and mammary (Bronchophony and whispering pectoriloquy)

Crepitation was felt on the left infraaxillary region

CVS
Normal S1 S2 heard
No murmurs
Apex beat felt on 5th intercostal space

CNS
No focal deficits seen

Investigations



Chest X ray:





Diagnosis:
Left upper lobe consolidation.

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