CASE OF TUBERCULOSIS
This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
A 65 year old male ,resident of bhuvangiri
worker by occupation came to casualty with
C/O-
ü
cough with blood since 3 months
ü
shortness of breath since 3 months
ü
chest pain since 6 months
ü
fever and chills since 8
months
HISTORY OF PRESENT ILLNESS-
Patient was
apparently asymptomatic 15 years ago,
then he developed giddiness on waking up early in the morning
since 15 years ,bilateral upper and lower limb tingling sensation and numbness
since 15 years ,
Dry mouth , polyphasia , polydypsia ,polyurea ,,
decreased vision in left eye since 5 years.
Fever(low grade,continuous) associated with chills since 8
months,
Dizziness ,chestpain on coughing and abdominal pain since 6
months,
Productive Cough with sputum since 6 months which progressed to
hemoptysis since 3 months accompanied by cold and SOB
Unintentional Weight loss of 20 kgs in 6 months(previous weight— 65 kgs)
Constipation ,loss of appetite,vomitings one episode after food
everyday since 3 months
Burning micturition,difficulty in defecation ,passes stools once
in 3 days.
Daily routine:- patient wakes up at 6 ,takes idly for breakfast and goes to work ,takes rice for lunch and returns home at 5, takes tea and does some daily chores and then takes rice or idly for dinner and sleeps at 9o’ clock
HISTORY OF PAST ILLNESS-
K/c/o
diabetes since 20 years
HTN since
20 years
No h/o
CAD ,
Epilepsy
PERSONAL HISTORY-
Diet – mixed
Appetite – loss of appetite
Sleep – inadequate
Bowel and bladder
movements- irregular
Micturition –burning
micturition
Addictions-
patient drinks
Ø Alcohol -1 bottle of
beer and toddy daily
Ø Smokes- 4 packs of
cigarette and beedi daily , stopped
completely since 2 months
FAMILY HISTORY-
No h/o similar complaints in family members
DRUG HISTORY:-
Tab. GLIPIZIDE and
METFORMIN for DM
Tab.ATEN-AT -25 for HTN
GENERAL
PHYSICAL EXAMINATION-
Patient was conscious ,coherent
and cooperative and examined in
well lit room ,well oriented to time ,place and person.
Moderately built and
moderately nourished
o no pallor
o no icterus
o no cyanosis
o no clubbing of fingers
o no generalised
lymphadenopathy
o no pedal edema
height- 160cm
weight-45kgs
VITALS-
§ Temperature – Afebrile
§ PR - 88 BPM
§ RR -20 breaths/min
§ BP - 150/90 mm Hg
SYSTEMIC
EXAMINATION-
I have examined the
patient in sitting position
CVS –
No thrills
S1,S2 heart sounds
heard
RESPIRATORY SYSTEM-
ON INSPECTION:-
Chest appears asymmetrical
Respiratory movements appear equal on both sides
Trachea deviated towards right side
No scars
ON PALPATION:-
All inspiratory findings are confirmed
Trachea deviated towards right
Apical impulse in left 5th inter coastal space ,1cm medial to mid clavicular line
Measurements:-
Chest circumference-31m on expiration
32 m on inspiration
Chest expansion- 1cm
AP measurement- 7m
Transverse - 13m
Vocal fremitus- felt on supra and infra scapular area
More vibrations felt on right side
ON PERCUSSION -
Right Left
Supra clavicular- R R
Infra clavicular- R R
Mammary - Dull R
Suprascapular- R R
Interscapular- R R
Infrascapular- R R
ON ASCULTATION:-
Right Left
Supra clavicular- NVBS NVBS
Infra clavicular- NVBS NVBS
suprascapular- NVBS NVBS
ABDOMEN-
Shape of abdomen –
scaphoid
No Tenderness
CNS-
Patient is conscious ,
Speech is normal,
Memory is intact.
PROVISIONAL DIAGNOSIS-
Pulmonary kochs
CAP
INVESTIGATIONS-
FINAL DIAGNOSIS-
Tuberculosis
Comments
Post a Comment