1601006148 LONG CASE

Long case-1601006148



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


Hall ticket number - 1601006148

April 24 , 2021

A34  year old male resident of Nalgonda labourer by occupation presented to opd on 24 april with CHIEF COMPLAINT of : 

• fever  since 10 days  

• Cough since 7 days 

• shortness of breath since 4 days 

- polyphagia,polyuria,polydipsia since 2 months

- Loss of weight

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days ago,then developed —

•fever which is insidious in onset ,with evening rise of temperature ,NO DIURNAL VARIATION, intermittent , not associated with chills and rigors , headache , vomiting 

Grade II shortness of breath and generalised weakness since 1 month followed by fever-low grade      

•  Cough with sputum since 7 days whitish,purulent which is insidious in onset , non progressive ,no aggrevating and relieving factors

• Grade II SOB  gradually progressive with chest thightness and difficulty in breathing since 1 month,no history of palpitation and syncopal attacks, no aggravating and no relieving factors

        . fever  which is insidious

• No History of burning micturition,loose stools,constipation,nausea,vomiting

• There is no history of sweating 

PAST HISTORY

• Not a known case of diabetes ,hypertension,asthma , convulsions,TB,CAD

• Surgical history is not significant.     

FAMILY HISTORY 

          No significant family history

PERSONAL HISTORY

• Decreased appetite 

• Vegetarian

• Regular bowel habits and normal 

• Patient has normal micturition

• He is an alcoholic since 14 years , drinks daily 90 mL

• He smokes daily 16-18 beedis/day

 GENERAL EXAMINATION

 Patient is conscious , coherent and cooperative , moderately built , moderately nourished

⁃ No pallor,no icterus , no cyanosis, no clubbing ,no pedal edema

⁃ No generalized lymphadenopathy   

 Vitals 

⁃ Pulse taken in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 

⁃ Bp 100/70 mm hg measured in sitting position on right upper arm 

⁃ Respiratory rate : 24cpm

⁃ Temperature:99.2 F

RESPIRATORY SYSTEM EXAMINATION

 Patient is examined in supine aswell as in sitting positions under well ventilated room with consent taken

 UPPER RESPIRATORY TRACT :

     nose , oral cavity are examined and no abnormal findings are present

EXAMINATION of CHEST PROPER :

INSPECTION

⁃ shape of chest : normal 

⁃ Symmetry of chest : symmetrical

⁃ Trial sign negative 

⁃ Movements of chest : RR -24cpm                                

                         TYPE - abdomino thoracic.                        

                         EQUAL on both sides 

⁃ No involvement of accessory muscles 

⁃ No visible scars , no sinuses , no engorged veins 

⁃ No deformities of spine 

⁃ No visible apical impulse

PALPATION

⁃ No tenderness and no local rise of temperature 

⁃ Inspectory findings are confirmed

⁃ Trachea central 

⁃ Apex beat : felt at 5 th Intercoastal space lateral to mid clavicular line

⁃ Decreased chest expansion 

⁃ Vocal fremitus : decreased at infra axillary and infra scapular areas on left side                                

 NORMAL on SUPRA CLAVICULAR , INFRACLAVICULAR , MAMMARY , INFRA MAMMARY , SUPRASCAPULAR and INTER SCAPULAR areas

PERCUSSION

Direct percussion: resonant on clavicle , sternum 

    2. Indirect percussion : 

  Anterior :

⁃ resonant in supra clavicular area 

⁃ Resonant in infraclavicular area 

⁃ Resonant in inframammary area on both sides 

⁃ Traube’s space:dull  

  Posterior :

⁃ Resonant in suprascapular area 

⁃ Resonant in interscapular area 

⁃ Dull in Infrascapular area on left side

AUSCULTATION   

⁃ Bilateral air entry present decreased on left side

⁃ Normal vesicular breath sounds heard on right side

⁃ Reduced AIR ENTRY IN LEFT MAMMARY,INFRA AXILLARY,INFRA SCAPULAR AREAS,WHEEZE IS PRESENT,COARSE CREPITATIONS

CVS EXAMINATION

⁃ S1 s2 heard 

⁃ No murmurs 

⁃ No palpable thrills

ABDOMINAL EXAMINATION

 Scaphoid shape 

No tenderness 

No palpable mass 

No hepatosplenomagaly 

No ascites 

Bowel sounds present

CNS EXAMINATION

⁃ Conscious and alert 

⁃ Normal gait 

⁃ Normal speech 

⁃ No signs of meningeal irritation 

⁃ Cranial nerves , motor system , sensory , glasgowcoma scale normal 

⁃ Reflexes : superficial and deep tendon reflexes are intact

INVESTIGATIONS 

⁃ CBP

⁃ CUE

⁃ ABG

GRBS 650 mg/dl



 

⁃ RFT 

⁃ LFT

⁃ PT

⁃ APTT

⁃ Blood sugar (hbA1c)

⁃ ESR 

⁃ Serum electrolytes

⁃ Blood culture 

⁃ Chest x ray 


⁃ Ultrasound abdomen 

⁃ Hrct 

- Ecg



- Rtpcr for covid-19

- Opthalmoscopy

DIAGNOSIS : DIABETES and LEFT LOWER LOBE CONSOLIDATION OF LUNG

Differential diagnosis:pneumonia.           

Pulmonary tuberculosis

Covid-19

Lung abscess

Bronchiectasis

Bronchogenic carcinoma

TREATMENT 

⁃ NIL BY MOUTH

⁃ IVFLUIDS NS AND RL

⁃ GRBS MONITORING  hourly(both fasting and post prandial)

⁃ INJECTION AUGMENTIN

⁃ Input and output charting

⁃ Bp pulse spo2 charting     

- INJ. HAI INFUSION


 

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