Medicine practical examination. LONG CASE HALL TICKET NUMBER :1701006056

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Hall ticket number:1701006056
Case:
A 70 year old male who is a construction worker by occupation came with chief complaint of
-Shortness of breath  from 25 days
- cough from 25 days
- Fever from 4 days
History of presenting illness :
- The patient was apparently asymptomatic 25 days ago ,then he developed shortness of breath which was insidious in onset , aggravated on exertion and relieved on rest and no shortness of breath on lying down(MMRC 
Grade 3)
-Cough from 25 days which is associated with sputum which is mucoid ,not blood stained,non foul smelling and no aggravating factors and relived on rest
-Fever from 4 days which is of low grade ,continuous ,not associated with chills and rigor
-Chest pain on the right side of chest which is of dragging type
- There is history of loss of weight and loss of appetite
Past history:
-No history of similar complaints in the past 
-No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid problems
Personal history:
-Appetite is reduced
-Diet is mixed
-Bowel and bladder habits:- regular
-Sleep :- adequate 
-Addictions :- 
- He is occasionally alcoholic
-He smokes 4 beedis per day since 50 years.
Family history :
-No history of similar complaints in family 
General examination:
The patient was examined in a well lit room after taking a valid informed consent after adequate exposure 
Patient is conscious, coherent and cooperative 
Thin built and moderately nourished
Pallor :- Present 
Icterus :- Absent 
Cyanosis :- Absent 
Clubbing-Present
Lymphadenopathy :-Absent
Pedal Edema :-Absent 
Vitals:
Temperature:98.5
Pulse rate:
-Rate :90bpm
-Rhythm :- Regular 
- Volume :- normal
-  Character :- normal
-  Condition of vessel wall :- Normal
 - No radio radial or Radio femoral delay  
Blood pressure :- 
- 120/80 mmHg taken from Left arm ,measured in sitting position
DAY 1 
BP- 110/80 mm hg
pulse- 88 bpm
respiratory rate -28 cpm
spo2 -96% 
DAY 2 
 BP -120/80 mm hg
pulse -89 bpm
respiratory rate -26 cpm
spo2 -96% 
DAY 3 
BP -120/80 mm hg 
PULSE -94 bpm
RR-14 cpm
SPO2 -92% (on room air )
96% ( with 2 lits of oxygen)
GRB 108mg /dl
 DAY 4 
BP -120/80 mm hg 
PULSE -90 bpm
RR-24cpm
SPO2 -96% (on room air )
DAY 5
BP -120/80 mm hg 
PULSE -88 bpm
RR-22cpm
SPO2 -98% (on room air )
DAY 6
BP -120/80 mm hg 
PULSE -92 bpm
RR-24cpm
SPO2 -91% (on room air )
97% (with 2 lits of oxygen) 
Systemic examination:
Respiratory system:
Inspection:
Upper respiratory tract-normal
Inspection:
-Shape of chest is bilaterally symmetrical and elliptical
-Trachea is deviated to right
-Movements are reduced on right side
-Apical impulse is not visible
-No sinuses,scars,dilated veins visible
-No evidence of usage of accessory muscles
-No bony abnormalities on chest
Palpation
-No local rise of temperature
-No tenderness
-All the inspectory findings are confirmed 
-Trachea is deviated towards right side
-Inspiratory measurement : 31 inches
-Expiratory  measurement:31.4 inches
-Chest expansion is by 1cm
-Chest diameters 
        Transverse :- 27 cm
        Anteroposterior :-20 cm 
-Movements of chest with respiration are reduced on right side 
-Apical Impulse is felt at 5th intercostal space 1 cm medial to mid clavicular line
Vocal fremitus:Increased on right infra clavicular and Supra scapular

Percussion:.             
                                    Right.            Left
Suprclavicuar.           Resonant.    Resonant
Infra clavicular.        Dull note.       Resonant
Mammary.                Resonant.      Resonant
Axillary.                     Resonant.     Resonant
Supra scapular.         Dull.             Resonant
Infra scapular.         Resonant.     Resonant
Auscultation
-Normal vesicular breath sounds heard 
-Diminished breath sounds on
 right infraclavicular area and Right suprascapular area 
-No added sounds 
Cardiovascular system: 
Inspection- 
-The chest wall is bilaterally symmetrical
-No dilated veins, scars or sinuses are seen
-Apical impulse not visible  
Palpation-
-Apical impulse is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
-No parasternal heave felt
-No thrill felt
Percussion- 
-Right and left borders of the heart are percussed 
Auscultation-
-S1 and S2 heard
, -No murmurs are heard 
Abdominal examination:
-Abdomen is soft and non-tender
-No organomegaly seen
Central nervous system:
-Higher mental functions are normal 
-Sensory and motor examinations are normal
-No signs of meningeal irritation
Provisional diagnosis:
Right upper lobe consolidation
Investigation
Haemogram:
Interpretation:
-Haemoglobin is reduced
-Total count is increased
Complete urine examination:
Liver function test:

Interpretation
-Alkaline phosphatase is raised
-Toral protein is reduced
culture and sensitivity:


ECG:
Chest x-ray

TREATMENT:
DAY 1
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 

 DAY 2 
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 


DAY 3
  
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 

DAY 4

injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 
injection optineuron 100ml OD 
Syrup Ascoril 2 tspns TID 

DAY 5 

injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 
syrup cremaffin 10 ml (per oral ) 

DAY 6 
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD 
Nebulization with Budecort BD ,DUOLIN TID 
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD 
syrup cremaffin 10 ml (per oral ) 





 







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