general medicine case of 73yr old male
Case:
A 73 year male who is a resident of gonaboynapally, came to OPD with
Chief Complaints:
Breathlessness since 10 days.
Epigastric pain since 4 days.
History of present illness:
Patient was asymptomatic 12years back and developed cough(insidious in onset, progressive, associated with expectoration) for which he went to hospital and diagnosed with tuberculosis.4years back patient had developed swelling in his scrotum and underwent hydrocele surgery. Since 2 months patient is having breathlessness on and off for which he used to go near by RMP and use medication and used to drink alcohol to get sleep. 10 days back patient had developed severe shortness of breath and got admitted in area govt. hospital and was diagnosed with tuberculosis (CBNAAT) on 3/11/22. SOB of grade IV, gradual chronic onset, associated with cough(productive and white in color), no relieving factors.
History of past illness:
Not known case of DM, HTN, CAD, asthma.
Treatment history:
12 years back took TB treatment for 6 months.
Underwent hydrocele surgery 3 years ago.
Personal history:
Diet: mixed
Appetite: lost since 10 days.
Sleep: inadequate
Bowel and bladder: irregular
Addiction:
Drinks alcohol regularly since 40years.
Smoked for 30 years quitted 12 years back.
Family history: not significant.
General Examination:
Patient is conscious, coherent and cooperative, well oriented to time, place and person.
Pallor: No
Icterus: No
Cyanosis: No
Clubbing of fingers: Yes
Lymphadenopathy: No
Pedal oedema: No
Vitals:
BP: 140/100
Pulse rate: 127 per min.
Respiratory rate: 40 per min.
SpO2: 97%
GRBS: 128 mg/dl
Systemic Examination:
CVS: S1,S2 are heard
No murmurs.
Respiratory system examination :
Inspection :
Position of trachea central
Slight dropping of right shoulder
intercostal indrawing
No supraclavicular hallowness
Shape and symmetry of the chest abnormal.
No dilated veins.
No visible scars.
accessory muscles of respiration not prominent.
Palpation :
On three finger test : position of the trachea central.
Respiratory movements are decreased on right side.
Measurement of left and right hemithorax :
46cm equal on bothsides.
Antero posterior diameter :24cm
Transverse diameter at the level of nipples :30.5cm
AP/transverse diameter ratio = 5.75/7.87.
Distance between vertebrae and infrascapular angle on right and left side is same =13cm.
Vocal framitus :. Right. left
Supraclavicular area. Reduced. N
Infraclavicular area. Reduced. N
Mammary area. Reduced. N
Axillary area Reduced. N
Infraxillary area Reduced. N
Suprascapular area. Reduced. N
Interscapular area. Reduced. N
Infrascapular area. Reduced. N
Percussion :
On direct percussion in clavicular area
On right side :
On left side :
Tidal percussion: dullness in the right 5 th intercostal space even after deep inspiration.
Traubes space percussion : dull note
Ascultation :
Vocal resonence :
Right left
Supraclavicular area. Reduced. N
Infraclavicular area. Reduced. N
Mammary area. Reduced. N
Axillary area Reduced. N
Infraxillary area Reduced. N
Suprascapular area. Reduced. N
Interscapular area. Reduced. N
Infrascapular area. Reduced.
Decreased vesicular breath sounds on right side.
Bilateral air entry positive.
No crackles heard.
Abdomen:
Inspection: no scars seen.
Palpation: tenderness in epigastric region.
Auscultation: Bowel sounds heard.
CNS Examination:
Cranial nerves intact.
No focal neurological deficit
Provisional diagnosis:
- Pulmonary tuberculosis.
- Anterior wall MI.
- HFrEF
- Non oliguric renal AKI
Clinical images:
Investigations:
Blood urea level:
HIV test:
Serum Electrolytes:
LFT:
Serum Creatinine:
ECG:
Final diagnosis:
- Pulmonary TB
- Anterior wall MI.
