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.
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