1601006109 SHORT CASE

 

1601006109 short case


Case:
-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 which was more during the night and was relieved on medication 

He then developed Cough which gradually progressed more during the nights and associated with sputum. It aggrevated during exposure to colder climates .The sputum was scanty and yellow which was non foul smelling (most probably bacterial infestation).

Cough was associated with Chest pain which was non radiating in nature and aggrevated on lying down relieved on sitting upright 

He later developed Dyspnea which went on to interfere his daily activities Grade 3 according to MMRC.

-Past history 
 TB : 5 yrs back and was treated with anti tubercular drugs.
No history of Asthma ,Diabetes Mellitus ,Hypertension ,Epilepsy ,siezures

-Family history-Not relevant 

-Personal history :
Appetite-normal
Sleep: inadequate 
Bowel and bladder- regular
Diet: Mixed
No food or drug allergies 
Addictions : smoking since 40 yrs ( 3 to 4 cigarettes a day,smoking index-(no.of cigarette*years) -3*40=120.Pack years-6

-Differential Diagnosis
Pneumonia 
TB
COPD 

-General Examination :
Patient was conscious coherent and cooperative 
 undernourished,under built

-Vitals 

Pulse- 84 bpm, Regular ,Normal volume 
Bp -100/70 mm hg
Respiratory rate -24 cpm 
On physical examination 
There is no Pallor
                     Icterus 
                     Cyanosis 
                     Clubbing 
                      Lymphadenopathy
                      Edema 
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 of chest

Shape and symmetry :Elliptical and symmetrical 

No visible pulsations 
No visible scars or sinuses

-Dimensions AP 16.5 cm
                    Transverse 23.5 cm

-Chest expansion -decreased 

Vocal fremitus -was increased on left infra clavicular and mammary area

Apex beat was felt on 5 th intercostal space medial to Mid clavicular line

On purcussion dull note was heard on 
-Left infra clavicular
-Left mammary 
-Left infra scapular

AUSCULTATION ON CHEST

-bronchial breath sounds are decreased

-There was an Increased vocal resonance and crepitations on left infra clavicular and mammary area.


CVS :
Normal S1 S2 heard 
No murmurs
Apex beat felt on 5 th intercoastal space 

CNS:No focal deficits seen

INVESTIGATIONS

PROVISIONAL DIAGNOSIS
Fibrosis in the left apical region probably due to old pulmonary tuberculosis.

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

1601006168 SHORT CASE

Image
  MEDICINE SHORT CASE This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  CASE PRESENTATION: 34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of  Chest pain
Read more