1701006011 CASE PRESENTATION
LONG CASE
19 years old male patient residency nalagonda came to OPD with chief complaints of :
1) breathlessness since 10days
2)fever since 10 days
3) cough since 3 days
HISTORY OF PRESENTING ILLNESS
Breathlessness since 10 days which is insidious in onset (mmrc grade 1)
-Aggravates on exertion and left lying posistion
-relieved on sitting and rest
Associated with weight loss about 5kg in 2months
Not associated with
-palpitations wheeze orthopnea paroxysmal nocturnal dyspnea
Fever since 10 days low grade on and off fever which is not associated with chills
Cough since 3 days without expectorant ( dry cough ) occassionally more during morning time
PAST HISTORY
History of weight loss about 5kg in 2 months
No history of palpitations chestpain hemoptysis
No history of similar complaints
No history of tuberculosis in past
No history of recurrent trauma history
Not known case of DM HTN TB BRONCHIAL ASTHMA
PERSONAL HISTORY
Mixed diet
Occupation student
sleep is adequate ( but disturbed from past few days)
loss of appetite is present
bowel and bladder movements are regular
No addictions
FAMILY HISTORY
no similar complaints in family
GENERAL EXAMINATION
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
he is conscious, coherent and cooperative, moderately built and nourished.
no signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy
VITALS:
Temperature : Afebrile
Pulse rate : 98 beats/min
BP : 110/70 mm Hg
RR : 16 cpm
SpO2 : 98
INSPECTION
Shape of chest : elliptical
Bilaterally symmetrical chest
Trachea appears central in posistion
Expansion of chest Decreased on left side
Use of accessory muscle for respiration not seen
No drooping of shoulder
Supraclavicular infraclavicular hollowness not seen
Spino scapular distance is equal on both sides
PALPATION
All inspectory findings are confirmed
No local rise of temperature
No tenderness
Trachea deviated to right side
Chest movements decreased on left side
Tactile vocal fremitus decreased on left side
Intra scapular area
Vocal resonance decreased on infrascapular area of left side
PERCUSSION
Left:
-direct : dull
-Indirect : dull
-liver dullness from right 5th ics
-cardiac dullness within normal limits
Right
- normal ( resonant )
AUSCULTATION
-Bilaterally air entry present
-vesicular breath sounds heard
-decreased intensity of sound on left inframammary infra axillary
- CVS EXAMINATION:
26 year old female who is a resident of nalgonda and housewife came with the complaints of
▪ Lower back ache since 15 days
▪ Fever since 10 days
HISTORY OF PRESENTING ILLNESS
▪Patient was apparent asymptomatic 15 days back then she developed severe lower back ache which was insidious in onset and gradually progressive and continuous type which was squeezing in character and not a radiating type of pain and it gets relieved by medication and the injection given by local doctor there are no associated symptoms
▪ Then she developed fever 10 days back which was insidious in onset which started as chills then developed fever which was gradually progressive and associated with chills and rigors more during night times
▪ She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication given on 4th june
▪ She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine, there is a feeling of incomplete voiding of urkne
▪ she had puffiness of face and abdominal distension on 6th june and got subsided
▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints
PAST HISTORY
▪ no similar complaints in the past
▪Patient had history of chest pain when she was 10 years old diagnosed rheumatic heart disease for which she was on medication for it but no subsided so surgery was done( CABG , MITRAL VALVE REPLACEMENT) then she was on prophylaxis for 2 years then she discounted then she had c section done 7 months back as baby is weak she consulted doctor from then she again started the penicillin prophylaxis
▪ She has a history of PCOS for which she is on medication
▪ not a known case of diabetes, Hypertension, asthma, tuberculosis
MARITAL HISTORY
3rd degree consangious marriage , 6 years back and had 7 months old baby
FAMILY HISTORY
not significant
PERSONAL HISTORY
Diet - mixed
Appetite- normal
Sleep - decreased because of pain
Bowel and bladder movements - regular
no addictions
no allergies
MENSTRUAL HISTORY
menarche - 13 years
regular periods
5/ 28 - moderate flow
not associated with pains
GENERAL EXAMINATION
Patient is conscious coherent cooperative well oriented to time , place , person moderately built and moderately nourished
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing - absent
Lymphadenopathy - absent
Edema- absent
VITALS
Pulse- 70 bpm
Respiratory rate- 34 per min
Blood pressure- 120/ 70 mm hg
Temperature - afebrile
SYSTEMIC EXAMINATION
Per abdomen
INSPECTION
shape of abdomen- normal
c section scar is seen and stria gravidarum
no abdominal swellings seen
no dilated veins are seen
no visible peristalsis
all quadrants are moving equally with respiration
PALPATION
No local rise of temperature and no tenderness
no palpable mass
no hepatomegaly and no spleenomegaly
Kidney - ballatoble
PERCUSSION
resonant sound heard
ASCULTATION
Bowel sounds heard
CVS
INSPECTION
midline scar is seen
shape of chest - normal
no precordial bulge seen
JVP not raised
no visible pulsations
PALPATION-
Apex beat felt at left 5th intercoastal space 2.5 cms lateral to mid clavicular line
Ausculatation -
S1 , S2 heards
no murmurs
click sound heard ( without stethescope)
INVESTIGATIONS
on day 1
Hemoglobin- 9.8
Total leukocyte count- 21900
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia
LIVER FUNCTION TEST
Appt- 51secs
Pt -25 secs
INR- 1.8
Random blood sugar- 101 mg/ dl
Urea- 26
Electrolytes
Serum creatinine- 1.4
Sodium- 141meq
Pottasium- 3.4
chloride- 106
day 4th
Hemoglobin- 10.1
Urea- 18
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