1601006098 LONG CASE

May 01, 2021

General Medicine Long Case

Hall ticket no : 1601006098

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A 45 year old male resident of Nalgonda labourer by occupation presented with chief complaint of :

• shortness of breath since 10 days

• Cough since 10 days

• Pedal edema since 10 days

History of presenting Illness:-

Patient was apparently asymptomatic 10 days ago,then developed —

• Grade III shortness of breath which was insidious in onset , nonprogressive,aggravated by walking and strenous work and dressing , relieved by sitting

There is history of orthopnea

There is no history of PND

• Dry Cough since 10days which is insidious in onset , non progressive ,no aggrevating and relieving factors

• Bilateral Pedal edema since 10 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors

. Fever since 10 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting

• History of burning micturition and oliguria since 5 days

• There is no history of sweating , palpitations , chestpain , hematuria

Past history

• 2 years back he developed symptoms of productive cough and fever for 1 week for which he visited to hospital and diagnosed with TUBERCULOSIS and took antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable )

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

• Surgical history is not significant.

Family history

Not significant

Personal history

• decreased appetite

• Mixed diet

• Regular bowel habits and normal

• Patient has oliguria and burning micturition

• He is an alcoholic since 10 years , drinks once weekly

• Smoker since 25 years , he smokes daily 2-5 beedis

GENERAL EXAMINATION

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

⁃ Presence of 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 130/80 mm hg measured in sitting position on right upper arm

⁃ Respiratory rate : 20cpm

⁃ Afebrile

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 -20cpm .

Type - abdomino thoracic.

. Equal on both sides

⁃ No involvement of accessory muscles and no intercoastal tenderness

⁃ 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 medial to mid clavicular line

⁃ Decreased chest expansion

⁃ Vocal fremitus : decreased at infra axillary and infra scapular areas on both sides normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas