1601006186 LONG CASE

 

1601006186 (LONG CASE)

 Demographics

34 year old male, labourer by occupation, from Narketpalli  

 Chief complaints

Fever since 10 days

Cough since 7 days

Breathlessness since 4 days

Presenting illness

Patient was apparently asymptotic 1 month back, then developed

Breathlessness which is invidious onset grade III(MMRC) and progressed from grade III to grade IV, not associated with postural variation or diurnal variation. Generalised weaknesses followed by low grade fever associated with chills, rigor, shows no diurnal variation, and 

cough since 7 days, associated with moderate amount of purulent sputum mixed with saliva , no postural variation, no loss of smell


Complaints of polyuria, polydipsIa, polyphagia since 2 months

No complaints of Palpitation, syncopal attack, cheats pain, haemoptysis, recurrent sore throat, hoarseness, choking episode, burning miturirition, loose stools, constipation.

Past history 

Not a known case of DM, hypertension, epilepsy, asthma, CVD, TB, thyroid disease

Family history 

None of patients attenders have similar symptoms, or have asthma, TB, hypertension, DM, CVD.

Personal history

Diet mixed

Appetite decreased

Sleep adequate

Alcohol consumption 70ml/day

Bladder and bowel regular

Drug history

No known drug allergies

Was on IV RL

General examination

After taking concent

I examined patient in supine and sitting position. 

Patient is conscious coherent cooperative well oriented to time place person, has wasting of muscles, is comfortable on bed.

There is no pallor, icterus, cyanosis koilonychias, clubbing, lymphadenopathy, pedal edema

 JVP is not elevated, hepatojuglular reflex absent.


 Vitals

Pulse rate 100 beats/min regular in rhythm character volume 

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

Respiratory rate 40  cycles per minute

Spo2 98% on room air.


Respiratory Systemic examination 

1. Upper airway

Nose normal alae Nasi, septum

Oral cavity teeth pharynx normal no sinus tenderness

2. examination of chest

INSPECTION 

Shape of chest elliptical

Trachea central

Apical impulse 5 inter coastal space medial to mid-clavicular line

Skin over chest is normal

Trail sign is absent

Supra clavicular and supra scapular hollwing is present


 PALPATION

No local rise of temperature

No tenderness

Chest is expanding equally on both sides

Tactile vocal fremitus is increased infra axillary infra scapular areas both sides

No palpable thrills capitation pleural rub

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 intercostal spaces are resonant, 5-7 intercostal spaces dull, posterity 9th intercostal space dull

Indirect percussion(right) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-5 intercostal spaces are resonant, 6,7 intercostal space are dull. posterity 9th intercostal space dull

Traube space dull

AUSCULTATION

Left side supraclavicular, infraclavicular, mammary, inframammary, suprascapular, normal vesicular breath sounds, decreased (bronchial) breath sounds at infraaxillary, scapular, infrascapular areas. Crepetations at infra scapular area

Right side supraclavicular, infraclavicular, mammary, inframammary, suprascapular,  normal vesicular breath sounds, decreased breath sounds at infraaxillary, infrascapular areas.

 Vocal resonance increased at infraaxillary, infrascapular areas on left side. 

Other system examination 

CNS - higher mental functions normal, cranial nerves normal, motor system normal, Reflexes normal, sensory system normal, no meningeal signs, no cerebellar signs

CVS - no visible pulsations, apical impulse on 5th intercostal space 1cm medial to mid clavicular line. S1 S2 heard no added murmurs

ABDOMEN - abdomen is scaphoid with all quadrants moving equally with respiration, umbilicus central and inverted, no abdominal tenderness, no organomegaly


INVESTIGATIONS:


GRBS 650 mg/dl








URINE FOR KETONES



Chest X-Ray

21 Apr 2021



22 Apr 2021


Provisional Diagnosis

Case of left lower lobe community acquired pneumonia. with possible diabetic ketosis.

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