53/M PTB

 A 52 year old male came to Pulmonology OPD with chief complaints of shortness of breath since 4 days 

Cough since 4 days 

Right sided chest pain since 4 days 

Fever since days

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 month back then he developed shortness of breath since which was grade 1 to 2 later progressed to grade 3 since 4 days which relieved on taking rest.he is also complaining of cough with sputum since 1 month mucoid non foul smelling,non blood stained aggravated since 4 days now he is having dry cough no aggravating and relieving factors.complaining of right sided chest pain since 1 month dull aching type non radiating pain which aggravated since 4 days chest pain is not associated with sweating, palpitations.complaining of fever since 3 days low grade not associated with chills and rigors evening rise of temperature present .Loss of appetite present since 1 month no loss of weight.


PAST HISTORY:

History of pulmonary tuberculosis present (sputum cbnaat positive on 27-7-2023 in external hospital)

He was started on ATT since 29-7-2023 4 tablets/day

Not a known case of HTN,DM,epilepsy,CVA,CAD

PERSONAL HISTORY:

Married

Takes mixed diet 

Daily wage labourer

Bowel and bladder are regular

Alcoholic since 25 years daily consumes 90ml of brandy stopped 1 month back

Non smoker

GENERAL EXAMINATION:

Patient is moderately build and nourished 

BP : 110/70 mmHg

PR : 132 bpm regular

Temp : 99F

RR: 30cpm

Grbs : 272 mg/dl

NO PALLOR , ICTERUS , CYANOSIS , CLUBBBING , EDEMA , LYMPHADENOPATHY


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM 

S1 S2 Heard 

no murmurs 

RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACT:

Nose - DNS towards right side 

Oral cavity - poor oral hygiene 

Posterior pharyngeal wall - normal

LOWER RESPIRATORY TRACT -

INSPECTION 

Shape of chest - elliptical and bilaterally symmetrical 

Chest movements decreased on right side

Trache - deviated to left 

Apex beat not seen

No supraclavicular and infraclavicular hallowness

No crowding of ribs

No drooping of shoulders , wasting of muscles

Usage of accessory muscles of respiration present 

No kyphosis , no scolosis

No scars , sinuses , engorged veins

PALPATION

No local raise of temperature 

No tenderness 

All inspectory findings are confirmed 

Trache deviated to left

Chest movements decreased on right side

Apex beat left 5 th intercoasral space 1 cm medial to midclavicular line

Tactile vocal fermitus - decreased on right side

Ap diameter 23 cms

Transverse diameter 29 cms

Right hemithorax 45 cms 

Left hemithorax 45 cms

Chest circumference on inspiration 90 cms expiration 88cms

PERCUSSION 

direct percussion- resonant on clavicle and sternum

Mediated - hyper resonant on right ISA,IAA,MA,ICA


AUSCULTATION:

Bilateral air entry present

Vesicular breath sounds 

Absent breath sounds in RIGHT MA,ICA,ISA,IAA

VOCAL RESONANCE - decreased on right side

PER ABDOMEN

Soft non tender

No organomegaly

Bowel sounds heard


CENTRAL NERVOUS SYSTEM 

No focal neurological abnormality detected.

PROVISIONAL DIAGNOSIS 

Right sided pyopneumothorax with pulmonary tuberculosis on ANTI TUBERCULAR TREATMENT.








ICD TUBE was placed on 22-8-2023 










PATIENT COMPLETED TREATMENT ON 07-05-2024 AND IS DOING WELL. HE RECEIVED ATT FROM KATANGUR GOVERNAMENT HOSPITAL.


OUTCOME - COMPLETED TREATMENT 





  


Comments

Post a Comment

Popular posts from this blog

THESIS BLOG LINKS

 1.  https://drkeerthimadireddy.blogspot.com/2023/04/57m-mdr-tuberculosis.html 2.  https://drkeerthimadireddy.blogspot.com/2023/04/67m-ptb-with-uncontrolled-type-2-dm-htn.html 3.  https://drkeerthimadireddy.blogspot.com/2023/04/80m-ptb-cap-aki-rhf-htn.html 4.  https://drkeerthimadireddy.blogspot.com/2023/04/67m-ptb-chronic-pancreatitis.html 5.  https://drkeerthimadireddy.blogspot.com/2023/04/20m-ankle-tb.html 6.  https://drkeerthimadireddy.blogspot.com/2023/04/64m-tb-meningitis-aki.html 7.  https://drkeerthimadireddy.blogspot.com/2023/04/65m-tuberculosis.html 8.  https://drkeerthimadireddy.blogspot.com/2023/11/48f.html 9.  https://drkeerthimadireddy.blogspot.com/2024/01/49-m-ptb-denovo-dm.html 10.  https://drkeerthimadireddy.blogspot.com/2023/04/60f-ptb-dm2-cad.html 11.  https://drkeerthimadireddy.blogspot.com/2023/04/50m-ptb.html 12.  https://drkeerthimadireddy.blogspot.com/2023/07/55m-malnutrition-ascitis-tb-peritonitis.html 13.  https://drkeerthimadireddy.blogspot.com/2023/07/60m-so
Read more

57/M MDR TUBERCULOSIS

Image
  A 57 yr old male lorry driver resident of gopalayapalli came to opd with chief complaints of  generalised body swelling since 1 month  decreased urine output since one month chest pain since 4 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic one month back later he developed swelling of face followed by abdomen and limbs which is pitting type since one month.  He had decreased urine output since one month.Intially there was dribbling of urine later there was complete stoppage of urine. He had chest pain since 4 days which was sudden in onset, dragging type,radiating towards back,and aggravated at night. H/o low grade fever associated with chills intermittent since one month. H/o shortness of breath (grade 3) since 1 month  H/O cough associated with sputum since one month and not relieved on medication. It is not associated with chest pain and no diurnal variation. Sputum is blood tinged. He had 9 sessions of dialysis (on alternate days) from one month last sessio
Read more

67/M PTB CHRONIC PANCREATITIS

Image
A 67 year old male, resident of kodhada, farmer by occupation, came to the hospital with chief complaints of: Pain Abdomen since 3 months.  HISTORY OF PRESENTING ILLNESS:  Patient was apparently assymptomatic 3 months ago, then he developed pain abdomen, which is continuous, insidious in onset, gradually progressive, squeezing type, non radiating, aggravated on coughing and deep inspiration and relieved on lying down down on right side. H/O loss of weight from the past 3 months (10kgs)  No H/O vomitings or gurgitation No H/O malena No H/O hematemesis No H/O nausea No H/O cough No H/O fever PAST HISTORY:  Pt is Not a K/C/O DM / HTN / TB / Asthma / Epilepsy / CVA / CAD H/O NSAID use on and off from past one year, but continuously from the past 3 months. No previous surgical history No drug or food allergy  No previous history of TB  PERSONAL HISTORY: Appetite: Decreased due to pain Diet: Mixed Sleep: adequate Bowel and bladder: regular Addictions:  History of Alcohol consumption since 47
Read more