SHORT CASE-1

A 50 years old male,  mason by occupation and resident of Bhongir, came to the hospital with chief complaints of fever since 2 months, and loss of appetite since 2 months.

History of presenting illness

A 50-year-old mason who was happily living with his family daily wakes up at 5 am, goes for a walk to get milk, and returns home. He then has tea with biscuits and rice for breakfast, then leaves for his work by 9 am. He has rice, for lunch, with curries at his workplace. He comes back from work at either 7 or 8 pm. He has rice for dinner at 9 pm and goes to sleep by 10 pm.

But his happy life was not so happy from the last 2 months when he developed Fever which was insidious in onset, intermittent in nature, low grade with no chills and rigors, no aggravating, and relieving with medication.

2 months back while he was working he felt generalized weakness & body pains for which he left work early and went to home. The next day morning he had fever for which he bought some tablets from a local pharmacy.

2 days later he was taken to a local ayurvedic by his family members on suspicion of jaundice where he was given some herbal medicine 3 doses (1 dose/week) and advised of some dietary restrictions.

Even after 3 weeks, his fever doesn't come down and he felt no change in his general condition.

He also lost his appetite gradually since 2 months, and history of weight loss since 2 months.

Since 20 days, his fever increased usually more in the evenings which would continue the whole night, and reduce by morning, and is associated with chills for which he was brought to our hospital.

Patient also complained of on & off pain in the abdomen in the umbilical and right lumbar region, which was insidious in onset, gradually progressive, non-radiating, aggravated while walking (around 100 meters), and relieved on rest.

H/o burning micturition present

No h/o urgency, frequency, incontinence, polyuria, polydipsia, nocturia, or urethral discharge.

No h/o sore throat, cough, or cold

No h/o vomiting, diarrhea

No h/o rash over the body, bleeding gums, Malena

No h/o headache, photophobia, involuntary movements, altered behavior

No H/o pedal edema, SOB, chest palpitations, chest pain, and tightness. 


Past History 

Patient is a known case of pulmonary tuberculosis 25 years ago, for which he used ATT for 6 months.

Not a known case of DM, HTN, CVA, CAD, thyroid disorders, asthma, and epilepsy.


Personal history 

Diet - mixed 

Appetite - decreased since 2 month 

Bowel & Bladder habits: Regular

Sleep - decreased

Addictions - 90 ml occasionally since 35 years.


Family history 

No similar complaints 


Surgical history 

Appendicectomy was done 30 years ago


General examination 

Examination was done in a well-lighted room, with consent and informing the patient in the presence of a female attendant.

Patient was conscious, coherent, and cooperative, well oriented to time, place, and person.

Pallor - present 

Icterus- absent 

Cyanosis- absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - absent

  


 



 


Vitals 

Temperature- 38⁰ C 

PR - 105bpm

RR - 23 CPM 

BP - 100/60 mmHg

SpO2 - 99% at RA

GRBS - 114mg/dl


SYSTEMIC EXAMINATION 


RESPIRATORY SYSTEM 

Patient examined in the sitting position 


Inspection 

Lips and tongue normal

Oral candida - absent

Poor oral hygiene



Trachea appears to be central

Shape appears to be elliptical, B/L symmetrical 

Mild wasting seen on right side supra scapular & infrascapular region

Respiratory movements appear equal on both sides and abdominothoracic type

No scars, sinuses, and dilated veins.

No lumps and Lesions 

No intercostal recession  


Palpation

All inspectory findings are confirmed

Apical impulse felt at 5th intercostal space and at the midclavicular line

Total circumference - 34 inches 

Hemithorax, Right - 17 inches Left - 17 inches 

Anterior Posterior - 8 inches 

Transverse - 12 inches

Chest expansion - 2 cms

Tactile vocal fremitus - Right               Left

Supraclavicular -.            increased        normal

Infraclavicular-                increased.       normal

Mammary-                        increased        normal

Axillary-                            normal             normal

Infra axillary-                   normal            normal          

Suprascapular-                normal            normal

Interscapular-                  normal            normal

Infrascapular-                  normal            normal


Percussion

Resonant in all regions  


Auscultation

Fine crepitations were heard in the infraclavicular area.

Normal vesicular breath sounds in other areas.

Vocal Resonance -       Right               Left

Supraclavicular -             increased        normal

Infraclavicular-                increased        normal

Mammary-                        increased        normal

Axillary-                            normal             normal

Infra axillary-                   normal            normal          

Suprascapular-                normal            normal

Interscapular-                  normal            normal

Infrascapular-                  normal            normal

Whispering pectoriloquy : present
No bronchophony or egophony


ABDOMINAL EXAMINATION 

Inspection 

Shape - scaphoid 



Umbilicus- centralized, inverted 

Scar present of appendicectomy 

No dilated veins 

No visible pulsations or peristalsis

Palpation: 

Soft, tenderness present in epigastrium & hypogastrium

Deep palpation- 

No organomegaly

Percussion:

No fluid thrill

Liver span 12 cms

Auscultation: 

No bowel sounds heard


CVS EXAMINATION 

Inspection: 

Shape of the chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation:

Apex beat can be palpable in the 5th intercostal space

Auscultation: 

S1,S2 are heard

No murmurs


CNS EXAMINATION 

Higher mental functions: intact

Cranial nerves intact

Motor examination: R L

Bulk. N N

Tone. N N

Power. N N

Reflexes:

Biceps. 2+ 2+

Triceps. 2+ 2+

Supinator 2+. 2+

Knee 2+.2+.

Ankle. 2+. 2+

Sensory examination: Normal

No meningeal signs


Investigations

Hemogram:

Hb - 10g/dl

PCV -29.3 vol%

Total leucocyte count - 6,300cells/cumm

RBC -3.08millions/cumm

Platelets-2.16lakhs/cumm


Serum electrolytes:

Sodium-134mEq/l

Potassium-3.9mEq/l

Chloride-103mEq/l


RFT:

Creatinine-1.2mg/dl

Urea -41mg/dl


LFT:

Total bilirubin-1.26mg/dl

Direct bilirubin-0.30mg/dl

AST-88IU/L

ALT-72IU/L

ALP-140IU/L

Total proteins-8.3gm/dl

Albumin-2.95gm/dl


RBS-94mg/dl


Serology:

HIV - Reactive

Anti-HCV antibodies -Nonreactive

HbsAg- Non reactive.


USG Abdomen:




ECG:




Chest X-RAY:






X- Ray LS spine:



L2 wedge compression Fracture



HRCT chest






Diagnosis:

Denovo Detected RVD + with ? Pulmonary TB reactivation

L2 wedge compression Fracture ? Osteoporotic / Pott's  spine

Right upper lobe fibrosis with traction bronchiectasis - old TB sequelae

K/c/o Pulmonary TB 25 yrs ago




Comments

Popular posts from this blog

THESIS

BIMONTHLY INTERNAL ASSESSMENT - MAY 2021

BIMONTHLY INTERNAL ASSESSMENT - DECEMBER