Final exam short case

19/01/2023


Chief Complaints:

        69year old female resident of Nalgonda, shopkeeper by occupation presented to casuality with chief Complaints of

Hoarseness of voice since 10 days.

cough since 1 week

breathlessness since 3 days  

fever (high grade) since 1 day, relieved on medication.


History of Present Illness:

         She was apparently asymptomatic 10 days ago, started complaining of noticeable change in her voice , horseness of voice which Started gradually, not associated with foreign body sensation, Difficulty in swallowing or any neck swelling.


Cough since 1 week, dry in nature ( not associated with any expectoration), not associated with cold, sore throat, Hemoptysis, loss of weight or appetite 


Shortness of breath since 3 days of grade 1- MMRC which was aggravated on walking And relieved on Taking rest, it was not associated with wheeze,  pedal oedema, orthopnoea and PND.  Fever high grade associated with chills since 1 day, with no diurnal variation  

no h/o chest pain or tightness 

There was no history of pain abdomen, nausea, vomiting, loose stools, burning micturition.

History of Past illness:

       H/o similar complaints in the last, 2 years ago, which relieved on medication.

       Known case of Hypertension since 5 years on medication, Metaprolol xL-50mg OD, Amlodipine 5mg OD.

     No h/o TB

      Not a known case of DM, Asthma, Epilepsy, CAD, thyroid disorders.

      No h/o inhaler usage in the past.

          

Personal History:

     Married

     Shopkeeper by occupation

     Appetite: Normal

     Diet: Vegetarian

     Bowel movements: Regular

     Micturition: Normal

     Sleep: adequate

     Addictions: no addictions

Family History:

      Not significant

Menstrual History:

 Age of menarche:  16 years

No of days of cycle:  28days

Menopause: 15 years ago


Obstetric History:

Age of marriage: 18years

Age at first child birth: 18 years

General Examination:

Patient is moderately built and nourished.

Patient is conscious, coherent cooperatively oriented to time and place

 Pallor:absent

Icterus:absent 

Cyanosis: absent

Clubbing: absent

Generalised Lymphadenopathy:absent







Vitals:

Temp:  afebrile

Respiratory rate:  22 cpm

Pulse:  94beats/min

Blood pressure:  110/70mmHg

Sp O2 : 92%

GRBS: 133mg/dl





Systemic Examination:


Respiratory system:

Position of trachea: central

Inspection:

 Upper respiratory tract examination:

 Nose- Right side nose hypertrophy

 Oral cavity- Normal oral hygiene.

Lower respiratory tract examination:

 Shape of chest- Barrell

 Trails sign  - absent

 Supraclavicular hallow- positive

 Chest expansion- decreased movements 

 No crowding of ribs, drooping of shoulders, wasting of muscles.

 Spinoscapular distance equal on both sides.

 Apical impulse not seen.

 No kyphosis/scoliosis 

 No sinuses, venous engorgements, visual pulsations.

Palpation:

 All inspectory findings are confirmed with palpation.

  Apex beat localised at Left 5th intercoastal space, 2cm median to mid clavicular line

  Tactile Vocal Fremitus is increased in left infraclavicular area

  Antero-posterior diameter- 21cms

  Transverse- 22cms

   

  Percussion:

                                 Right.             Left

Supraclavicular     Resonant.        R

Infraclavicular.         R.                   Dull

Mammary.               R.                   R

Axillary.                     R                  R

Infra axillary.            R                   R

Suprascapular.        R                 R

Interscapular.          R                 R

Infrascapular           R                R

Auscultation:

                                 Right.                 Left

Supraclavicular.  Normal vesicular   NVBS

                              breathe sounds

Infraclavicular.    NVBS.                      Tubular

Mammary.           NVBS                        NVBS

Axillary.                NVBS.                      NVBS

Infra axillary.       NVBS.                      NVBS

Suprascapular.    NVBS.                      NVBS

Interscapular.      NVBS.                     NVBS

Infrascapular       NVBS.                    NVBS


  Cardiovascular Examination:

Inspection:

Bilateral symmetrical chest

No visible engorged veins, scars or sinuses on chest 

Palpation:

S1 and S2 are heared 

No thrills or murmurs 

Apex beat is found at 2cms medial to 5th intercoastal space

Percussion :  

   Heart borders are appreciated

Auscultation:

No cardiac murmurs heard

Abdomen:

Inspection 

Shape of the abdomen -scaphoid

Umbilicus - central and inverted 

Sinuses and scars - not visible

No dilated veins

Palpation 

No local rise in temperature

No tenderness

No palpable mass

No organomegaly

Hernial orifice -normal

Free fluid - no

No bruits

Liver not palpable

Spleen not palpable

Percussion:-

 Resonate

Auscultation:-

Bowel sounds heard

CNS:

Patient is conscious , coherent, cooperative and we'll oriented to time and place.

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- normal

Memory intact

Investigation









Provisional Diagnosis:

    Left upper lobe fibrosis? 

Secondary to TB with? 

 ?vocal cord palsy? Malignancy of larynx.

Hypertension since 5years on medication 

    Tab.Metaprolol xl 50mg OD

    Tab. Amlodipine 5mg OD

Treatment:

Inj.Augmentin 1.2mg IV

Inj.Neomol 10mg IV

Inj.Pantop 40mg IV

Tab.Paracetmol 650mg TID

Syrup.Grillinctus 2tbsp TID

Neb.Duolin 8 hourly

Nen.Mucomix 12 hourly







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