1801006018 SHORT CASE

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This is a case that i examined last July of a patient who presented with a chief complaint of loose stools and generalised weakness.

History of Presenting Illness:

Patient was apparently asymptomatic 10 years back. Then he developed coughing for more than 3 weeks and was diagnosed with tuberculosis. He took treatment for 6 months and then got cured. 

The patient was fine after that other than an occasional fever or any other mild illness, he had no serious complaints.

Since one year, he said he has been coughing. It is usually dry but sometimes associated with very small quantities of mucus.

Then 4 months ago he developed wheezing and shortness of breath of grade 3/4. The patient described it as some sort of a high pitched sound in his throat. He went to a hospital and used some medication but he said it wasn’t effective.

Since 15 days, he has been frequently urinating. He urinates small quantities every 5-10 minutes.

Then on 27th June, he had 3-4 episodes of loose stools per day for 2 days which were non blood stained, watery of small quantity. He went to another hospital and took treatment and then came here after finding out he had low blood pressure.

On July 3rd, he complained of chest pain and epigastric pain radiating to his back. It was a piercing type of chest pain and increased on walking and inspiration and decreased on sitting. He also complained of feeling nauseas and bloated and he says he now feels constipated after coming here. He also says he feels breathless after eating or talking.

Insight about the patient:

Prior to being diagnosed with tuberculosis, the patient used to go to his fields and work there everyday. He grew paddy and raised cattle and goats. He stopped going out to work since 10 years and now stays at home. He regularly spends time with his children, grand children and great grandchildren and is a cheerful and active person.

He had a habit of smoking beedi for around 50 years but quit around 7-8 years ago when his physician advised him not too. He used to smoke almost 16-17 per day. He also occasionally consumed alcohol.

Daily routine last July 2022:

The patient wakes up at 5 AM and freshens up. He has tea and if he feels like it he goes to his farm and checks upon the farm work. He has breakfast at around 9 am and then rests for some time. He has lunch at 1 pm and rests for an hour. In the evenings he spends time with his family or by himself or chats with the neighbours. He takes dinner at 8 pm and goes to bed.

Daily routine in March 2023

Patient now only occasionally goes and checks farm work, rest of the daily routine remains the same

Past history:

When he was about 20 years old, a bull rammed into his right knee, and since then he has been walking with a limp.

When he was 25 years old, he had an appendicectomy

No history of Diabetes, hypertension

Personal history:

Diet: mixed

Appetite: decreased

Sleep: has sleep disturbances since the past few days.

General examination

Patient is conscious, coherent and cooperative. Well oriented to time place and person.

Pallor: absent

Icterus: absent

Clubbing: present

Cyanosis: absent

Lymphadenopathy: absent

Edema: present 

Vitals:

Temp: 93 F

BP 90/60

Heart rate 65 bpm

Resp Rate 18 /min 

SpO2: 94%

GRBS: 98 mg/dl

               

      3-7-22 no pedal edema                                                           4-7-22 pitting type of pedal edema seen

        

        

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity hygiene not maintained. Tongue has fissures and looks dehydrated

Chest appears barrel shaped

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea appears central & Nipples are in 4th Intercoastal space

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-

All inspiratory findings confirmed

Trachea is deviated to the right

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

MEASUREMENTS-

AP diameter-                  9.7 inches on right side and 9.3 inches on left side

Transverse diameter-    10.7 inches

AP/T ratio - 0.91

Respiratory movement's:- decreased on Right side. 

Tactile vocal fremitus- equal on both sides

Percussion:-

                                       Right                     left

Supraclavicular- Resonant (R)                 (R) 

Infraclavicular-              (R)                        (R) 

Mammary-                     (R)                      (R)

Axillary-                          (R)                        (R) 

Infra axillary-                (R)                       (R) 

Suprascapular-             (R)                        (R) 

Interscapular-               (R)                        (R) 

Infrascapular-               (R)                         (R) 

Auscultation:-

  

                        diffuse crepts heard in all lung areas

                              

                                     

Cardiovascular System :

Inspection :  

Precordium :

 No precordial bulges.

No engorged veins.

No scar/sinus.

JVP: https://youtu.be/x0fvkrKEPlg

Other findings :

Patient is using accessory muscles to breathe.

Apex Beat : appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.

Chest wall Defects : None.

 

PALPATION : 

Inspectory finding of Apical beat correlated on Palpation, can be

 localized 1cm lateral to the midclavicular line in the 5th  

Intercostal Space.

AUSCULTATION : 

S1 ,S2 heard.

 

Note :Diffuse crepitations in all the lung areas.

ABDOMEN

Soft and non tender

CNS:

No focal neurological deficits

INVESTIGATIONS:

complete blood picture:

Haemoglobin:12.4

Platelet count:1.64

Total leucocyte count:9,100

COMPLETE URINE EXAMINATION:

Albumin trace

Sugar Nil

Pus cells 4-5

RBC 3-4

Epithelial cells 3-4

LIVER FUNCTION TEST:

Total bilirubin: 0.46

Direct bilirubin: 0.20

Alkaline phosphatase: 93

Albumin: 3.31

RENAL FUNCTION TEST:

 

Urea 40

Creatinine 1.6

Uric acid  6.1

Arterial blood gas:

Pco2: 27.5

PH: 7.38

Hco3: 18.6

Po2: 62.4

7)chest x ray:

Chest X ray findings:

Fibrosis in upper lobes

Pulmonary Kochs

Straightening of left border of heart

Tubular heart

Blunt right CP angle

Mediastinal shifting to left side

9)ECG:

DIFFERENTIAL DIAGNOSIS

Acute gastroenteritis with old pulmonary kochs

COPD

pulmonary fibrosis secondary to tb

Cor pulmonale

JULY 5TH 2022

S: pt c/o chest pain 

Sob reduced 

No fever spikes 

Cough reduced

O: o/e pt c/c/c 

Afebrile

BP - 110/70 mmhg

PR - 100bpm

CVS - S1S2+

RS - BAE+ wheeze + 

Spo2 - 92% at RA

RR - 20cpm

A - Acute gastroenteritis (resolved) 

Old pulmonary kochs 

Cor pulmonale

P:

Neb with budecort , duolin

Tab ecospirin AV po od

Tab met xl 12.5 po od

 

JULY 6TH 2022

S: pt c/o chest pain 

Sob reduced 

No fever spikes 

Cough reduced

O: o/e pt c/c/c 

Afebrile

BP - 110/70 mmhg

PR - 100bpm

CVS - S1S2+

RS - BAE+ wheeze + 

Spo2 - 92% at RA

RR - 20cpm

A - Acute gastroenteritis (resolved) 

Old pulmonary kochs 

Cor pulmonale

P:

Neb with budecort , duolin

Tab ecospirin AV po od

Tab met xl 12.5 po od

Inj tramadol 100mg in 100ml NS 

Tab lasix 20mg po bd

Syp cremaffine plus 15ml po hs

AT PRESENT

Patient is feeling better and is able to do his daily activities. He still has cough occasionally. He regularly gets check ups done at his local hospital every 2-3 months