GENERAL MEDICINE FINAL PRACTICAL 1601006026 SHORT CASE

HALL TICKET NO 1601006026 SHORT CASE

A 51 year old male gentlemen resident of Miryalaguda, farmer by occupation, presented with a chief complaints of  
 Fever since 10 days 
 Cough with sputum since 10 days 
 Shortness of breath since 7 days 

History of present illness

Patient was apparently asymptomatic 10 days back then he developed 
Fever which was insidious in onset, associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication 
He then developed Cough with expectoration which is gradually progressive more during the nights followed a similar diurnal pattern.It aggrevated during exposure to colder climates.The sputum was scanty and yellow in color, 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( MMRC grade 3/4)
No history of wheeze, hemoptysis

Past history 
History of tuberculosis 5years back for which he took anti tubercular drugs and got treated 
Not a known case of 
Asthma 
Diabetes Mellitus 
Hypertension 
Epilepsy 
FAMILY HISTORY 

Not relevant 
No food or drug allergies 

Personal history 
Diet: Mixed
Appetite: normal
Bowel and bladder: regular
Sleep: Adequate
Addictions : smoking since 40 yrs ( 3 to 4 cigarettes a day )

      Smoking index 120
      Alcohol since 40 yrs  

GENERAL EXAMINATION 
 Patient was conscious coherent and cooperative 
Moderately built and nourished

Vitals 
Pulse-
82 bpm
Regular
Normal volume 
Bp 100/70 mm hg
Respiratory rate 29 cpm 

On physical examination 

Pallor absent

Icterus absent 

Cyanosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 

Systemic examination 
Respiratory 

Upper respiratory tract examination 

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

Shape and symmetry :Elliptical and symmetrical 
Trachea :Appears to be central
Spine: central
Respiratory movements decreased on both sides
Breathing pattern was Thoracoabdominal
No visible pulsations 
No visible scars or sinuses
Palpation 

Trachea is central
Dimensions AP 16.5 cm
                    Transverse 23.5 cm





Chest expansion was equal on both the sides

Vocal fremitus was increased on left infra clavicular and mammary region

Apex beat was felt on 5 th intercostal space medial to MCL

Percussion 

On percussion dull note was heard on 
Left infra clavicular
Left mammary 
Left infra scapular

Auscultation

Bronchial breath sounds 

There was an Increased vocal resonance on left infra clavicular and mammary 
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

DIFFERENTIAL DIAGNOSIS
Pneumonia 
Tuberculosis
COPD 
Investigations

Provisional Diagnosis
Pneumonia with Left Upper lobe consolidation

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