55M ? PTB

 A 55 Year old male came with chief complaints of cough since 1 month 

fever since 1 month

Generalised weakness since 1 week

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 months ago then he developed dry cough which is insidious in onset more during the night, fever which is low grade not associated with chills and rigors no aggravating and relieving factors evening raise of temperature present.Generalised weakness since 1 week insidious in onset gradually progressive.Weight loss of 10-15 kgs in a span of 2 months

Loss of appetite since 2 months 

PAST HISTORY 

Used ATT for 2 months 

He had similar complaints 2 months ago and went to local hospital and x ray was taken ( patient was informed x ray suggestive of tb and ATT initiated and his symptoms improved after taking att for 5 days )

No sputum sample was examined months ago.

Not a known case of hypertension, diabetes mellitus, bronchial asthma , cva, coronary artery disease.


PERSONAL HISTORY 

Takes mixed diet 

Occupation: construction work

Appetite lost since 2 months

Bowel and bladder regular

Alcoholic since 40 years 90ml/day whiskey

Smoker 1 pack beedi since 40 years


FAMILY HISTORY 

No significant family history 


GENERAL EXAMINATION:

Patient is moderately build and nourished 

BP :100/70 mmHg

PR : 126bpm regular

Temp : 99F

RR: 28cpm

Grbs : 107 mg/dl

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


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM 

S1 S2 Heard 

no murmurs 

RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACT:

Nose - normal

Oral cavity - poor oral hygiene 

Posterior pharyngeal wall - normal

LOWER RESPIRATORY TRACT -

INSPECTION 

Shape of chest - elliptical and bilaterally symmetrical 

Chest movements decreased on left side

Trache - appears central 

Apex beat not seen

No supraclavicular and infraclavicular hallowness

No crowding of ribs

No drooping of shoulders 

wasting of muscles present 

No kyphosis , no scolosis

No scars , sinuses , engorged veins

PALPATION

No local raise of temperature 

No tenderness 

All inspectory findings are confirmed 

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

Tactile vocal fermitus - increased on left side

Ap diameter cms

Transverse diameter cms

Right hemithorax cms 

Left hemithorax cms

Chest circumference on inspiration  cms expiration  cms

PERCUSSION 

direct percussion- resonant on clavicle and sternum

Mediated -  resonant on left  ISA,IAA,MA,ICA


AUSCULTATION:

Bilateral air entry present

Vesicular breath sounds 

Decreased intensity of breath sounds in LEFT MA,ICA,ISA,IAA


PER ABDOMEN

Soft non tender

No organomegaly

Bowel sounds heard


CENTRAL NERVOUS SYSTEM 

No focal neurological abnormality detected.

PROVISIONAL DIAGNOSIS 

?PULMONARY TUBERCULOSIS 










AFB SEEN AND SPUTUM CBNAAT POSITIVE AND STARTED ON ATT 4 TABS/DAY.ON 29-09-2023.




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