MD EXAM----->SHORT CASE-1

CHEIF COMPLAINTS 

55yr male Tiles construction worker came with complaint of

Generalised weakness :- 2 months

                         Fever  :- 2 months

                 Dry cough  :-2 months                        

HISTORY OF PRESENT ILLNESS 

Patient was apparently alright till 2months back then he had insidious onset of fever, intermittent, relived on taking medications,not associated with chills and rigors.

Fever is associated with generalised weakness(not able to perform his previous routine job works) and dry cough(which is insidious onset, intermittent,relived on taking medication, no aggravating factors, not associated with positional or seasonal variation)

History of weight loss, loss of appetite present.

No history of coughing of blood, chest pain, palpitations,swelling of lower limbs, facial puffiness, decreased urine output

PAST HISTORY

History of pulmonary tuberculosis 25years back,used ATT for 6months.No history of interventional procedures done during that period.

Not a known case of DM/HTN/CAD/CVA/EPILEPSY/Thyroid disorder/Retroviral illness

PERSONAL HISTORY

Takes alcohol 90ml whisky per day for past 30years

Tobacco chewer for 30years

Takes mixed diet,appetite decreased from past 2months,regular bowel and bladder movements,adequate sleep

FAMILY HISTORY

No history of similar illness in the family

GENERAL EXAMINATION

Patient is conscious, coherent,co-operative

Moderately built and nourished

No Pallor,Icterus,Cyanosis,Clubbing,Lymphadenopathy,Pedal edema

Oral candidiasis +

Spine deformity-Dorsal thoracic vertebra Gibbs +

VITALS :-

PR:-80bpm,regular rhythm,normal volume, all peripheral pulses felt

BP-110/80mmhg,In right upper limb sitting position

RR-28/min,Abdominothoracic type, regular 

Temperature:99 F

SPO2 : 99% on Room air

Grbs-120mg/dl

JVP-Not elevated










SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

Upper respiratory tract :

     Nose--external nose normal, no deviated nasal septum

     Oral cavity--Poor oral hygiene,Oral thrush +

Lower respiratory tract :

  Inspection :

-Trachea appears to be in centre

-No scars, sinuses,dilated veins over the chest

-Apical impulse not visible

-Chest-Bilaterally symmetrical/Elliptical

-Chest movement Decreased on right side

-On examining back of the chest in standing position, with arms hanging by the side of the body

      No drooping of shoulder

      Spinal deformity present -->Dorsal thorassic vertebrae Gibbus +

Palpation :

-Trachea--Central



-Apex beat--1.5cm medial to mid clavicular line in the left 5th intercostal space

-Respiratory movements --decreased on right side with respiration

-Chest Measurements :

       Anteroposterior diameter-18cm

               Transverse diameter-28cm

     Ratio of AP diameter : Transverse diameter :



       Chest circumference :85cm

       Vocal fremitus  : Increased on right side of chest

Percussion : Resonant

Auscultation:

Supraclavicular & Infraclavicular : Bronchial breath sounds +

Vocal Resonance:increased on right side of chest


Added sounds :

Inspiratory crepts present on the right side of chest

OTHER SYSTEM EXAMINATION

CARDIOVASCULAR:

-Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

PER ABDOMEN :

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard

CENTRAL NERVOUS SYSTEM

-Higher mental functions intact

-Cranial nerves - intact


-Sensory system-normal


-Motor system -normal

 PROVISIONAL DIAGNOSIS :          

?Re-activation of pulmonary Tuberculosis

INVESTIGATIONS

Radiological






BLOOD

CBP

    Hb-10.4gm/dl

    TLC -5400cells/cumm

     Plt - 1.98lakhs/cumm

LFT

   TB-1.2 mg/dl

   DB-0.3 mg/dl

   AST-88 IU/L

  ALT-72 IU/L

  ALP-553 IU/L

    TP-8.3gm/dl

  ALB-2.9gm/dl

RFT

  Sr Na/k/cl--133/4.3/96

  Sr cr-1.2mg/dl

  Sr urea-41mg/dl

RBS-94mg/dl

Serology

HIV 1/2  Rapid test --->Reactive


Sputum for AFB & CBNAAT : Negative


FINAL DIAGNOSIS :

?Reactivation of Pulmonary Tuberculosis

Newly Detected Retrovirus illness

Osteoporotic Fracture of dorsal thoracic vertebrae

Bronchiectasis(?Past TB Sequlae)


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