General Medicine final practical examination
70 year old male with Shortness of breath
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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.
S.Neeraja Reddy
H.tno 1701006170
Long case
General medicine final practical
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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