hall ticket number :1601006025
HALL TICKET NUMBER :1601006025
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51-Year-Old Male Patient Farmer by occupation resident of Miryalaguda .
He came up with a chief complaint:
1. Fever from 10 days
2 .cough with sputum from 10 days
3. Shortness of breath from 7 days
History of present illness
The patient was apparently asymptomatic 10 days back, then developed the
Fever which is insidious in onset , continous and it was associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication, he developed Cough with sputum which gradually progressive , more during nights followed a similar diurnal pattern. It aggravated during exposure to colder climates. The sputum was scanty and yellow which was non-foul smelling.
Cough associated with chest pain which was non-radiating in nature and aggravated on lying down, relieved on sitting upright.
He later developed gradually Dyspnea which went on to interfere with his daily activities (indicating MMRC Grade 3).
Past History:
No history of Asthma, Diabetes Mellitus, Hypertension, and Epilepsy.
TB: 5 Years back and treated with complete course of Anti tubercular drugs.
Family History:
Not relevant
Personal History:
Sleep: inadequate
Bowel and bladder movements: regular
Appetite: Normal
Diet: Mixed
No food or drug allergies
Addictions:
Smoking from 40 years (3 to 4 cigars/day) (Smoking Index: 120)
Pack years:6
Examination
The patient was conscious, coherent, and co-operative
Seems to be undernourished
Vitals
Pulse: 82 bpm | Regular | Normal Volume
BP: 100/70 mm of Hg
Respiratory Rate: 30 cycles per min
On Physical Examination
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema absent
Systematic Examination:
Respiratory system examination,
Upper respiratory tract examination
Nostrils: Normal
Nasal septum: No deviated nasal septum
Nasal polyps: No nasal polyps
Tonsils: No enlarged tonsils
The posterior pharyngeal wall appears to be normal
Inspection of chest:
Shape and symmetry: Elliptical and symmetrical
Spine: Central
Trachea: Appears to be central
Breathing pattern normal
No visible pulsations
No visible scars or sinuses
Palpation:
Spine is central
Trachea is central
Transverse 23.5 cm
Chest expansion decreased
Vocal fremitus was increased on the left infraclavicular and mammary regions.
Apex beat was felt on 5th intercostal space medial to MCL.
Percussion
On percussion dull note was heard on
Left infraclavicular
Left mammary
Left infrascapular
Auscultation
Tubular(bronchial)breath sounds heard.
There was an increased vocal resonance on the left infraclavicular and mammary.
Crepitation was felt on the left infraaxillary region
CVS
Normal S1 S2 heard
No murmurs
Apex beat felt on 5th intercostal space
CNS
No focal deficits seen
INVESTIGATIONS
Complete urine examination
Hemogram
Diagnosis:
Left upper lobe consolidation
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