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.

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