1601006018 SHORT CASE

GENERAL MEDICINE SHORT CASE

This is an E log book to discuss our patient de- identified health data shared after taking his/her consent 


A 51 year old male patient resident of Miryalguda , farmer by occupation ,presented with a chief complaint of  

1. Fever  since 10 days 

2. Cough  with sputum since 10 days 

3. Shortness of breath since 7 days 


History of present illness

Patient was apparently asymptomatic 10 days back then developed following symptoms 

Fever which was insidious in onset and it was associated with chills and rigors with diurnal variation (continuous fever) which was more during the night and was relieved on medication 

He developed Cough with sputum which  gradually progressed more during the nights followed a similar  diurnal pattern . It aggrevated  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 aggrevated on lying down relieved on sitting upright 

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


Past history 

No history of:

Asthma, Diabetes Mellitus ,Hypertension, Epilepsy 

TB : 5 yrs back,he was treated with anti tubercular drugs(ATT)

Family history

Not relevant 

Personal history 

Sleep:inadequate.

Bowel and bladder regular

Appetite: normal

Diet: Mixed

No food or drug allergies 

Addictions : smoking  since 40 yrs ( 3 to 4  cigarettes a day )

      Smoking index =120 

     Pack years =6

Examination 

 Patient was conscious coherent and cooperative 

Seems to be undernourished 

Vitals 

Pulse

  •  82 bpm
  • Regular
  • Normal volume 
Bp 100/70 mm hg

Respiratory rate 30 cpm 

On physical examination 

Pallor absent

Icterus absent 

Cynosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 


Systemic examination 

Respiratory 

Upper respiratory tract examination 

  • Nostrils : Normal
  • Nasal septum: No deviated nasal septum
  • Nasal polyps: No nasal polyps
  • Tonsils :No enlarged tonsils
  • Posterior pharyngeal wall appears to be normal

Inspection 

  • 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 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 purcussion dull note was heard on 

    • Left infra clavicular
    • Left  mammary 
    • Left infra scapular


    Auscultation

    Tubular(Bronchial) breath sounds .

    There was an Increased  vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)

    Crepitation were felt on left infra axillary region

    Cvs 

    Normal S1 S2 heard 

    No murmurs

    Apex beat felt on 5 th intercoastal space 

    CNS

    No focal deficits seen

    Investigations


    Provisional Diagnosis:
    Left Upper lobe consolidation

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