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