1601006196 LONG CASE

 

1601006196 (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 10 days back, then developed  fever which was continuos type associated with chills and rigors .

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

Breathlessness which is incidious onset grade III(MMRC) and progressed from grade III to grade IV, not associated with postural variation or diurnal variation.


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, 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 4-6 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 4-7 intercostal spaces are resonant. 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 Decreased 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. 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


Complete blood picture

Random blood sugar



Serum electrolytes 


Arterial blood gas


Urine for ketone bodies


Blood urea




Serum creatinine



Chest X-Ray




Provisional Diagnosis

Case of left lower lobe pneumonia With possible diabetic keto acidosis.

Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought to the hospital by her family members, at around 
Read more