1701006170 CASE PRESENTATION
LONG CASE:
70 year old male resident of nalgonda farmer by occupation came with chief complaints of
*Shortness of breath since 20 days
*Cough since 20 days
History of present illness
Patient also complained of cough with sputum which is mucoid in consistency non foul-smelling non blood tinged.
No postural or diurnal variation and no aggrevating factors.
Cough Relieved on medication
Patient gives similar history 10 years back and was treated.
Patient gives history of loss of weight(around 5 kgs ) and loss of appetite .
No history of hemoptysis
No history of sore throat or wheezing.
No history of fever ,decreased urine output syncopal attacks.
No history of hospitalization in the past month
Past history
History of tuberculosis in the past used medication for 4months.
No history of Hypertension Diabetes Bronchial Asthma Epilepsy.
Family history
Not significant
Personal history
He takes Mixed diet
Appetite is reduced
Bowel and bladder movements are regular
Addiction:Alcoholic since 20 years
Smoking- smokes around 2chuttas per day.stopped 10 years ago
No known allergies
Respiratory system
INSPECTION
Upper Respiratory tract
Nose: no Dns , no polyps no hypertrophy of turbinates.
Poor oral hygiene.
Lower respiratory tract
shape of the chest is elliptical
Trachea appears to be central
No drooping of shoulders
Supraclavicular hollowness and infraclavicular hollowness present
Chest expansion is equal on both sides.
Apical impulse is not seen
No visible pulsation or scars or engorged veins.
No crowding of ribs
No kyphosis or scoliosis
No usage of accessory muscles for respiration.
wasting of muscles present
Spinoscapular distance is equal on both sides.
PALPATION
All Inspection findings are conformed
No tenderness
No local rise of temperature
Restriction of movement on right side of chest.
Trachea is central
Apex beat felt at left 5th intercostal space.
Tactile Vocal fremitus is equally felt on both sides
Ap diameter 21 cms transverse 25 cm
I percussed the following areas
ANTERIOR. Right. Left
Supraclavicular Resonant. Resonant
infraclavicular. Resonant. Resonant
Mammary. Resonant. Resonant
LATERAL
Axillary. Resonant. Resonant
Infraaxillary. Dull. Resonant
POSTERIOR
Suprascapular. Resonant. Resonant
interscapular. Resonant. Resonant
infrascapular. Dull. resonant
PERCUSSION
Direct Percussion over manubrium sterni and clavicle resonance note was heard.
dullness noted over right infrascapular area, infra axillary area
Kronigs isthmus not obliterated
Traubes space not obliterated.
AUSCULTATION
Bilateral air entry is present
Decreased air entry in right infra scapular area and infra axillary area.
No additional sounds heard
Vocal resonance decreased in right infraaxillary area.
ABDOMINAL EXAMINATION
INSPECTION:
•Shape – scaphoid
•Flanks – free
•Umbilicus –central in position , inverted.
•All quadrants of abdomen are moving equally with respiration.
•No dilated veins, hernial orifices, sinuses
•No visible pulsations.
PALPATION:
•No local rise of temperature and tenderness
•All inspectory findings are confirmed.
•No guarding, rigidity
•Deep palpation- no organomegaly.
PERCUSSION:
•There is no fluid thrill , shifting dullness.
Percussion over abdomen-
tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
INSPECTION:
•Chest wall - bilaterally symmetrical
•No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
•Patient is Conscious, well oriented to time, place and person.
•All cranial nerves - intact
•Motor system: Intact
•Superficial reflexes and deep reflexes are present , normal
•Gait is normal
•No involuntary movements
•Sensory system -
-All sensations pain, touch,temperature, position, vibration, are well appreciated.
Provisional diagnosis
Right sided pleural effusion secondary to TB
Investigations
XRAY chest
Complete blood Picture
Liver function tests
Renal function tests
ECG
2D ECHO
Chest x ray
TREATMENT:
Inj Augmentin 1 to 2 gm iv Tid
Inj pan 40mg iv /od
Tab mucinac Ab TID
Tab paracetamol 650mg sos
Syrp Ascoril TID
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SHORT CASE:
58 year old farmer by farmer byoccupation resident of suryapet came with chief complaints of
Edema in both the legs since 5 days
History of present illness
Patient was apparently asymptomatic 5 days ago where he developed pedal edema in both the limbs pitting type which was Insidious in on set gradually progressive.
No aggrevating or relieving factors.
10 days ago he went to one hospital due to sob grade 4 and underwent 2 sessions of dialysis.
History of 2 blood transfusions.
No history of burning micturition, no urinary disturbances
No history of fever chills or rigors.
No history of NSAIDS abuse.
Past history
No history of Hypertension Diabetes Bronchial Asthma Epilepsy thyroid tuberculosis
Family history
Not relevant
Personal history
He takes mixed diet
Appetite normal
Bowel and bladder movements are regular
Non smoker
occasional alcoholic
No known allergies
Clinical images
GENERAL EXAMINATION
Patient is conscious coherent and coperative well oriented to time place and person.
Vitals
Afebrile
BP 110/70mmhg
PR 90bpm
Respiratory rate 18 cpm
Mild pallor
Icterus Cyanosis Clubbing Lymphadenopathy
Bilateral pedal Edema pitting type upto ankle
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
INSPECTION:
•Shape – scaphoid
•Flanks – free
•Umbilicus –central in position , inverted.
•All quadrants of abdomen are moving equally with respiration.
•No dilated veins, hernial orifices, sinuses
•No visible pulsations.
PALPATION:
•No local rise of temperature and tenderness
•All inspectory findings are confirmed.
•No guarding, rigidity
•Deep palpation- no organomegaly.
PERCUSSION:
•There is no fluid thrill , shifting dullness.
Percussion over abdomen-
tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
INSPECTION:
•Chest wall - bilaterally symmetrical
•No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
INSPECTION:
•Chest is bilaterally symmetrical
•Trachea – midline in position.0
•Apical Impulse is not appreciated
•Chest is moving normally with respiration.
•No dilated veins, scars, sinuses.
PALPATION:
•Trachea – midline in position.
•Apical impulse is felt on the left 5th intercoastal space.
•Chest is moving equally on respiration on both sides
•Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
• Supraclavicular-resonant
•Infraclavicular- resonant
•Mammary- resonant
•Axillary- resonant
•Infraaxillary- resonant
•Suprascapular- resonant
•Infrascapular- resonant
• interscapular - resonant.
AUSCULTATION:
•Normal vesicular breath sounds heard
•No adventitious sounds
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
•Patient is Conscious, well oriented to time, place and person.
•All cranial nerves - intact
•Motor system: Intact
•Superficial reflexes and deep reflexes are present , normal
•Gait is normal
•No involuntary movements
•Sensory system -
-All sensations pain, touch,temperature, position, vibration, are well appreciated.
Investigations
Hiv test
Hiv non reactive
PROVISIONAL DIAGNOSIS
CHRONIC KIDNEY DISEASE ON dialysis
Treatment
1.Tab Lasix 40mg BD
2.Tab Pantop 40 mg /po/OD
3.Tab Nodosis 500mg BD
4.Tab Orofer XT Po/OD
5.Cap Bio D3 /po weekly once
6.Inj Erythropoietin 4000 U s.c weekly once
7.Tab Nicardia 5mg /sos
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