1601006154 LONG CASE

 

Long case

Age :  40 years

Sex : Male

 Occupation : labourer 

Address : narketpally , nalgonda 


Chief complaints - 

Fever  since 2 weeks
Cough Since 1 weeks 
Difficulty in breathing since 1  weeks 
Chest pain since 4 days

History of present illness - 

Patient was apparently asymptomatic 2 weeks  ago, then developed 
          FEVER  since 2 weeks ( on and off )
             Onset - insidious 
             Low grade 
             Relieved on medication     
             Not associated with chills and rigors 
             No diurnal variation 
          
           COUGH 
             Since 1 weeks
             Initially non productive 
             Later associated with purulent sputum                     mixed with saliva 
               Color - pale yellow 




           BREATHLESSNESS 
               Since 1 week 
               Onset : insidious 
               Initially grade 2 (MMRC) 
               progressed to grade 4 
               With no postural variation 
      
           Chestpain on left side since 4 days
           present on inspiration and coughing                         non radiating and relieved on lying down.
 
 No complaints of hemoptysis 
               palpitations, syncopal attacks 
               Joint pains
               Loose stools , constipation 
        

Past history - 

Not a known case of DM , Hypertension , Asthma, TB , Epilepsy , CVD 

FAMILY HISTORY 

No similar complaints in family

PERSONAL HISTORY 

Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
Smoker since 10 years (smoke 10 - 15 beedis/day)

General Examination

Patient was examined in sitting position after obtaining consent
He is conscious coherent and cooperative and comfortably sitting on bed 

 patient is of lean built and appears toxic and fattigued

No evidence pallor, icterus , clubbing , cyanosis, koilonychia , Pedal edema
Jvp is not elevated 
 

Vitals

Temperature : Afebrile, 98 F

Respiratory rate- 40 cycles per minute

Pulse rate 100 beats/min regular in rhythm character volume 

Blood pressure 90/70 mmHg left arm in sitting position.

Spo2 97% on room air.

Systemic Examination


Respiratory system: 
1. Upper airway-
      Nose normal alae Nasi, septum is not deviated

Oral cavity - teeth gums tomsils normal 
  no sinus tenderness

2. Examination of chest

INSPECTION

Shape of chest - elliptical

Trachea appears to be central
Trail sign is absent 

Apical impulse is not visible

Tachypnoea
Abdomino thorasic respiration 

Skin over chest is normal 

Hollownesss in supraclavicular and supraspinatous fossa




    


PALPATION 

No local rise of temperature
No tenderness
Chest is expanding equally on both sides
Tactile vocal fremitus is increased in infrascapular and infra axillary areas
Trachea is central 
Apex beat is normal position 




 

PERCUSSION

Direct percussion on clavicle, sternum and Manubrium is resonant 

Kronig isthmus resonant both sides

Indirect percussion(left) 
   anteriorly 
      mid claviclular line 2-6 intercostal spaces are        resonant. 
   Laterally 
       mid axillary line 4-6  intercostal spaces are             resonant,  
5-7 intercostal spaces dull( woody), 
   posteriorly
     9th intercostal space dull
      Traube space is dull.

Indirect percussion(right) anteriorly mid   claviclular line 2-6 intercostal spaces are   resonant. Laterally mid axillary line 4-7   intercostal spaces are resonant. posterity 9th   intercostal space resonant.

AUSCULTATION

Left side infra clavicular, mammary, supra scapular - normal vesicular breath sounds,

 bronchial breath sounds infracaxillary ,                          infrascapular areas 
  Increase in vocal reonance 
  Bronchophony 
  whispering pectoriloquy 
   aegophony are present.

Right side infra clavicular, mammary, supra scapular, infra axillary, infra scapular areas-vesicular breath sounds

 

Other system examination 

CNS - no facial asymmetry all reflexes are normal 

CVS- S1 S2 heard no added murmurs

ABDOMEN - abdomen is scaphoid with no organomegaly

Chest Xray 















Provisional diagnosis - 

Left lower lobe consolidations probably due to community acquired pneumonia



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