MOHAMMED KHAIRUL FARHAN
Hall ticket No. 1701006114
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50 year old male by occupation resident of Miriyalguda brought to the casualty on 8/6/22
Chief complaints;-
1. Shortness of breath [Grade 4] since 1 year on/off
2. Headache to the occipital region since 20days which slowly progressed to Bilateral Parietal region along with neck pain
3. Throat pain Pricking type since 3 to 5 days
History of Presenting Illness:-
The patient was apparently asymptomatic 1year back then he developed shortness of breath which was on off during this time period but since 20 days the patient started complaining of
Breathlessness since 20 days which is indidious in onset Grade 3 which is associated with wheezeing and Orthopnea +, Palpitation +
and also associated with fever since 15 days low grade not associated with chills and rigors decreased on medication
No C/o Cough, chest pain, chest tightness, haemoptysis
Past History:-
No Past history of TB and Covid 19
Not a Known case of Diabetes mellitus, Hypertension, Epilepsy
Family History: Insignificant
Personal History:-
Diet- Mixed
Appetite - Normal
Bowel- Regular
Bladder - Decreased Urine Output, Burning Micturation
Sleep - Adequate
Addictions- Smoking since 20 years, 1 pack daily , stopped 1 and half year
Inhaler Usage since 1 and half years, daily
General Examination:-
Patient was consicous, coherent and cooperative moderate built and well nourished at the time of presentation.
No Pallor Icterus Clubbing Cyanosis Lymphadenopathy Edema
Vitals:=
Pulse- 95bpm
Blood pressure- 110/80 mmHg
Respiratory Rate- 24cpm
spO2- 96% @RA
Systemic Examination:-
Respiratory System:-
INSPECTION :
Shape of the chest : scaphoid
Symmetry : bilaterally symmetrical
Trachea : Central in position
Expansion of the chest : Normal
Accessory muscles use for respiration : Not present
Type of respiration : Abdomino-thoracic
No dilated veins, pulsations, scars, sinuses.
No drooping of shoulders
No crowding of ribs
Spino-scapular distance equal on both sides
PALPATION :
All inspectory findings are confirmed
No local rise of temperature
No tenderness
Anteroposterior diameter- 21cm
Transverse diameter-30cm
Ratio: AP/T- 0.7
Chest expansion: 2.5 cm
PERCUSSION :
Left-
Direct : dull
Indirect : dull Liver dullness for right 5th intercostal space
Cardiac dullness within normal limits
AUSCULTATION :
Bilateral air entry present
Normal vesicular breath sounds heard
CARDIOVASCULAR SYSTEM :
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse and pulsations cannot be appreciated
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
PER ABDOMEN :
INSPECTION:
Shape – scaphoid
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
PALPATION:
No local rise of temperature and tenderness
All inspectorial findings are confirmed.
No guarding, rigidity
Deep palpation- no Hepatomegaly or splenomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM :
No focal neurological deficits
Sensory and motor systems intact
Normal power , tone and reflexes
INVESTIGATIONS :
COMPLETE BLOOD PICTURE
Hemoglobin 10.1 gm/dl
Total Count 5.800 cells/cumm
Neutrophils 59%
Lymphocytes 30%
Eosinophils 01 %
Monocytes 10%
Basophils 0%
Platelet Count 2.34 lakhs/cu.mm
Smear : Normocytic normochromic
MCHC AND PCV VALUES ARE LOWER
LIVER FUNCTION TESTS :
Total Bilirubin 1.31 mg/dl
Direct Bilirubin 0.33 mg/dl
SGOT(AST) 26 IU/L
SGPT(ALT) 24 IU/L
Alkaline Phosphate 172 IU/L
Total Proteins 6.1 gm/dl
Albumin 3.4 gm/dl
A/g Ratio 1.25
RENAL FUNCTION TESTS :
Urea 33 mg/dl
Creatinine 1.3 mg/dl
Uric Acid 5.7 mg/dl
Calcium 10.0 mg/dl
Phosphorous 3.1 mg/dl
Sodium 140 mEq/L
Potassium 3.6 mEq/L
Chloride 98 mEq/L
COMPLETE URINE EXAMINATIONS :
X RAY:
Ultrasound:-
ECG Report:-
Provisional Diagnosis;-
Shortness of Breath secondary to COPD with gliosis and small depressed frontal bone fracture
Treatment Given;
1 MINIMAL 02 SUPPLEMENTATION @ 2 LIT
2 TAB AUGMENTIN 625 MG PO/BD
3 TAB PAN 40 MG PO/OD
4 TAB ZINCOVIT PO/OD
Advice at Discharge:
1 CAP FORMONIDE 200 BD X2 WEEKS
2 CAP TIOVA 9 MCG OD X 2 WEEKS
3 TAB AUGMENTN PO/BD X 3DAYS
4 TAB PAN 40 MG PO/OD X 5 DAYS
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