Medicine Case Conference

Roll Numbers – 45, 47, 48, 49, 50

Demographic Details
• Mr. Ashu
• 27 years old , Male
• Resident of Chandni Chowk, New Delhi
• Educated upto 6th Standard
• Currently
• Unmarried
• Religion- Hindu
• The informant was the patient himself
Chief complaints
History of presenting illness
Past History
Personal History
Family History
Course during hospital stay
Summary
Differential Diagnosis
(Based on history)
Symptoms analysis
Examination
• The patient is conscious, cooperative, well oriented to time, place and
person sitting comfortably on bed with IV cannula in left hand.
• Adequate privacy maintained,
• Examination carried out in well-illuminated area
• Patient is average built (BMI= 26.4 overweight weight -72,height - 165cm)
• B.P is 110/78 mm hg in rt.brachial artery in sitting position at the level of
heart
• PR=60/min,taken in right radial artery, regular, normal in volume, vessel
wall normal, no radioradial or radiofemoral delay, peripheral pulses
palpable
• RR=20/min, thoracoabdominal, regular
• JVP not raised
• Febrile to touch temperature-101.6℃ taken in axilla
 Head to toe examination
•
Hair - coarse, black in color , normal in texture
• Facial symmetry maintained
• Eyes- pallor present , no icterus
• Nose - no deviation of septum seen, nasal mucosa didn't appear to be congested
• Lips -no pallor seen on mucus membrane, no angular stomatitis
• Tongue- smooth and flat, no pallor , no ulcer, no cyanosis
• no bleeding gums.
• Orodental hygiene– good
• Neck - no neck swelling
• Tonsil were normal
• No oral ulcers
• Nails–normal colour and texture clubbing absent.
• Lymphadenopathy not presen
Systemic examination
On Respiratory examination-

Inspection
• Trachea central in position
• Shape of the chest normal
• Chest is bilaterally symmetrical, no kyphosis,no scoliosis, no precordial bulging, no
bulging of ICS
• Decreased chest movement on right side
• Apical impulse not visible due to breast tissue
• No prominent veins over the chest wall
• No drooping of shoulder
• No crowding of ribs
• No widening of ICS
• Skin over the chest normal, no scars,no rash,no sinus
 Palpation
• On palpation trachea shifted to left side
• Apical beat felt in left 5th ICS medial to mid-clavicular line, normal in character
• Decreased chest movement in rt. Side and the expansion is 1.5 inch as measured
by tape
• Vocal fremitus decreased below 4th ICS on right side along MCL in mammary ,
inframammary and along scapular line in infrascapular area
• No tenderness of ribs and ICS
• No crowding of ribs
• No widening of ICS
 Percussion
• On percussion there is dullness in MCL from 4 th ICS downwards
• On left side chest is resonant.
• Hepatic dullness start from 5th ICS in rt. MCL

Auscultation
• Breath sounds absent on right side of chest in mammary, inframammary and infrascapular area
• Vocal resonance decreased on right side of chest in mammary, inframammary, and infrascapular
area
• Normal vesicular breath sound heard over rest of the chest
• No adventitious sounds heard
On abdominal examination
Inspection
• Abdomen Normal in shape
• No venous prominence
• Umbilicus central, inverted
• Flanks flat
• No scar marks, no ulceration,no fistula
• No localized swelling
• All hernial orifices are free and intact
• Movement of abdomen adequate in all quadrant
 Palpation
• On superficial palpation, abdomen is soft,no tenderness,normal in
consistency
• On deep papalpation
• Liver is enlarged 4 cm below the costal margin at rt MCL, non tender , firm in
consistency,margin is sharp, surface smooth, moves with respiration
• Spleen is palpable 5cm below the costal margin at left MCL, non-tender ,firm
in consistency,surface smooth,rounded splenic notch not felt,moves with
respiration
 Percussion
• Liver dullness started from 5 th ICS upto 4cm below rt. Costal margin in
MCL
• Liver span 16 cm
• Splenic dullness started in 8 th ICS upto 5cm below left costal margin in
anterior axillary line.
Auscultation
• Normal bowel movement 3-4 /min
Per rectal
• Consent not given

On cardiovascular examination
• S1, S2 heard, no murmur, apex beat present in 5th ICS.

On CNS examination
• higher mental functions intact , all reflexes intact
Differential Diagnosis
Provisional diagnosis
Investigations
CBC
• RBC - 3.89 million/ml
• WBC - 5900 / ml
• Hb - 10.7 g/dl
• DLC Neutrophil - 47.7%
• Haematocrit - 35.4%
• MCV - 91.0 fl
• MCH - 27.5pg
• MCHC - 30.2g/dl
• Platelets – 2,42,000 / microL
LFT
• Total bilirubin – 0.4mg/dl (0.02 mg/dl)
• ALT – 22 IU/L (<45 IU/L)
• AST – 31 IU/L (<35 IU/ L)
• ALP – 85 IU/L (53 – 128 IU/L)
CBNAAT - Negative
 CHEST X-RAY :
• Chest X- ray in a PA view was done in inspiratory phase which showed
normal bony shadows with no periarticular osteopenia. No obvious
deformities in soft tissue. No cardiomegaly seen.
• Homogenous opacity seen in right middle and lower zone with no
bronchovascular markings and a rim of opacity seen laterally around
the upper zone. Right costophrenic angle was obliterated.
Treatment
1. TPR | BP | spO2 chart
2. Prop up
3. flow O2 @ 2-3 L/min
4. Tab. Azeg 500 mg 1 OD
5.
6. Condom catheterisation
7. Plenty of fluids with ORS
8. Inj. Pantop 40 mg i.v. OD
9. Inj. Emeset 4 mg i.v. TDS