GENERAL MEDICINE LONG CASE FINAL EXAMINATION
January 20 2023
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Cheif complaint
Patient complains of breathlessness since 4days and cough since 3days.
History of present illness
Patient was apparently asymptomatic 4 days back then he developed breathlessness with gradual onset grade 2-3 associated with chest tightness ,wheeze , seasonal variation, aggrevated on cool air and dust.
Cough with sputum since 3 days , mucopurulent, non blood stained, not foul smelling, no seasonal variation, more during night time, aggrevated on cold exposure.
History of allergy with cough, watery eyes on exposure to dust.
No history of fever, palpitations, haemoptysis, chest pain, weight loss, loss of appetite, burning micturation.
History of past illness
Patient complains of similar history in past.
Admission to Hospital twice in 2018 and 2021 and diagnosed as acute exacerbation of asthma with bronchiectasis.
Pneumococcal vaccine taken on 19-10-21
Influenza vaccine on 20-10-21
Usage of inhaler formonide, with metred dose inhaler with spacer from 2 years and stopped since 1 month.
History of diabetes mellitus on medication
No History of TB, cad, epilepsy , hypertension.
Personal history
Married
Occupation - farmer
Diet - mixed
Bowel - regular
Appetite - normal
Micturation- normal
Allergies- dust , cold air
Addiction - toddy occasionally
No known family history
General examination
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, malnutrition, dehydration, edema of feet.
Vitals
Temp- afebrile
Pulse rate - 110/min
Respiration - 34/min
Bp-110/90mm of hg
Grbs - 98%
Spo2- 90% no of litres of o2
Systemic examination
Cvs
No thrills
Cardiac sounds s1s2 heard
No cardiac murmurs
Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest
Palpation:-
S1 S2 are heard
No thrills , no murmurs
Auscultation:-
Cardiac rate - 88 beats per minute
No cardiac murmurs heard
Respiratory examination
Inspection
Shape - barrel shape chest
Trail sign absent
Accessory muscles of respiration being used
Supraclavicular hollowness present
No infraclavicular hollowness
No crowding of rib, drooping of shoulder, wasting of muscles
Spinoscapular distance equal on both sides
Chest movements equal on both sides
Apical impulse not seen
No kyphosis, scoliosis
No sinuses, scars, engorged veins with pulsations
Palpation
All inspectort findings are confirmed
Apex beat palpable at left 5th ICS, 1.25 CM medial to mid clavicular line
Percussion
Direct resonance in clavicle and manubrium
Indirect resonance in all areas
Auscultation
Bronchial artery embolisation seen
Bilateral crepts seen in infraaxillary, mammary
, infra scapular
Bilateral rhonchi seen in interscapular, mammary
Abdomen
Inspection
Shape - normal
No distension
All quadrants moving equally with respiration
Umblicus is central and inverted
Skin over abdomen is normal
No visible scars
Palpation
Liver spleen not palpable
Cns
Patient is conscious
Speech normal
No kernings sign, neck stiffness
Motor and sensory systems normal
Provisional diagnosis
Acute exacerbation with bronchiectasis
Investigation
Cbp, lft, rft, 2d echo, x ray, sputum cbnaat, afb, fs,
Fever chart:
ABG 1 Date 19/2/2023
X ray
Syrup ascoril 1tsp po tid
Neb duoline 6th hourly
