39 year old male with cough and fever
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A 39 year old male who is a labourer by occupation came with the cheif complaints of cough since 1 week and fever since 1week
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1month back then he developed cough initially with sputum and later it turned to dry cough(non productive cough )since 1 week.for which he got admitted and diagnosed as left pleural effusion and now he is presenting with dry cough since 1 week gradual in onset and non progressive more in night and no aggravating and receiving factors. He also complains of fever since one week which is insidious in onset and low grade ,evening rise of temperature is present and subsided by medication .
No history of chest pain ,decreased urine output,sweating and palpitations.
HISTORY OF PAST ILLNESS:
Patient had a history of similar complaints in the past for which he has diagnosed with left pleural effusion and pleural tap done 1500 ml on 23/3/23and 25/3/23 and sent for pleural fluid analysis which reported total count of 5400 and pleural fluid ADA:4110/L,pleural sugar:211mg/dl,pleural protein:5.5g/dl
Patient is a known case of diabetes since 7 years on Glimi M1 ,not a known case of hypertension ,thyroid disorders,CAD ,TB,epilepsy.
PERSONAL HISTORY:
Patient is a labourer by occupation,he wakes at 6Am and goes to wash room freshup and drinks tea at 8am and at 9 an he goes to his labour work and 8to 1 am he does his work at 1 am he eats his lunch an after 1 am he again starts his work and he complets work by 5 pm and reaches home by 6 pm ,from 6 pm to 8 pm he spends his time by watching TV and after 8 he eats his dinner and sleeps at 9pm
Diet :mixed
Appetite:normal
Sleep:adequate
Bowel and bladder :Regular
Addictions:has the habit of chewing tobacco.
FAMILY HISTORY:No history of similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative Moderately built and moderately nourished. Well oriented to time place and person.
No pallor,icterus,cyanosis,clubbing,lymphadenopathy and edema.
Vitals:
BP:110/80MMHG
RR:18CPM
PR:86BPM
TEMP:99.6F
SYSTEMIC EXAMINATION:
EXAMINATION OF RESPIRATORY SYSTEM:
UPPER RESPIRATORY TRACT:
Nose :Normal.
No polyps
No Dns
No posterior pharyngeal wall congestion
No upper Respiratory tract infections.
LOWER RESPIRATORY TRACT:
Inspection:Trachea central
Shape of chest :symmetrical
Movements of chest:normal
No droopy or wasting of muscles.
No scars ,sinuses or engorged veins.
Abdominal thoracic type of breathing.
Apex beat not visible.
No kyphosis and scoliosis.
Palpation:
Trachea :central
Temp :Afebrile
All inspectory findings are confirmed
AP DIAMETER:30 CM
TRANSVERSE DIAMETER:26 CM
ON INSPIRATION:97 CM
ON EXPIRATION:96CM
RT HEMITHORAX:45CM
LT HEMITHORAX:45CM
Chest movements:Equal on both sides.
Apex beat on the left 5th intercostal space 1 lateral to mid clavicualr line.
PERCUSSION:Direct :Resonant
Indirect :Dull at left LAA,LSA.
AUSCULTATION:BAE Present
Normal vesicular breath sounds are present.
Decreased breath sounds on LAA AND LSA ON LEFT SIDE .
EXAMINATION OF CNS
no focal neurological deficits.
EXAMINATION OF CVS:
S1,S2heard and no murmurs.
EXAMINATION OF ABDOMEN:
Soft and no tender
Bowel sounds are heard.
Clinical images:
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