CASE PRESENTATIONonRespiratory Medicine<br />Moderator:<br />Dr. B. Laskar<br />Professor & Head<br />The Department of Me...
PATIENT  PARTICULARS<br />KHAGEN BARUAH<br />68 years; Male; Hindu<br />Retired Clerk from Assam State Electricity Board<b...
CHIEF COMPLAINS<br />Cough for last 1month<br />2. Chest pain for last 1month<br />
History of Present Illness: COUGH<br /><ul><li>Gradual onset, progressive
Harsh, forceful, wheezy and in frequent bouts
Persistantthro’out the day, more at night
Minimalmucoid expectoration with one episode of blood tinging</li></li></ul><li>History of Present Illness: COUGH<br /><ul...
Profuse expectoration
Alteration is quality of cough
Fever, night sweats
Post nasal drip, hawking, irritation in neck
PND
Audible wheeze by the family members</li></li></ul><li>History of Present Illness: CHEST PAIN<br /><ul><li>Gradual onset, ...
Located over anterior chest, w/o radiation or referral
Persistentthro’out the day , w/o any variation
Aggravated on coughing/deep breath w/o change in character
No postural, diurnal, temporal variation
Symptomatically improved after admission for last 5 days</li></li></ul><li>History of Present Illness: CHEST PAIN<br /><ul...
Sweating, palpitation, radiation to arms or neck
Sudden severe attacks requiring emergent care
Superficial skin eruptions
Trauma
Chest heaviness or tightness
Regurgitation of food, hawking
Exertionaldyspnea</li></li></ul><li>History of Present Illness: Positive History<br /><ul><li>The above symptoms were asso...
Weight loss over last 1 month
Malaise, muscle pain, headcahe
Pain in the back of neck… dull aching , aggravated by extremes of movement for last 14 days
Mild hoarseness of voice for last 14days
Hospitalisation for these complains 15 days back from where he was refferred</li></li></ul><li>History of Present Illness:...
Fever, recurring drenching night sweats
Pain abdomen,LBP,Bleeding from natural orifices
LOC, seizure, syncope
Flushing, diarrhea, skin eruptions
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Case Presentation On Respiratory Medicine

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Case Presentation On Respiratory Medicine

  1. 1. CASE PRESENTATIONonRespiratory Medicine<br />Moderator:<br />Dr. B. Laskar<br />Professor & Head<br />The Department of Medicine<br />Assam Medical College & Hospital <br />Dibrugarh<br />Presenter:<br /> Tanoy Bose<br />Post Graduate Trainee<br />Department of Medicine<br />Assam Medical College & Hospital<br />
  2. 2. PATIENT PARTICULARS<br />KHAGEN BARUAH<br />68 years; Male; Hindu<br />Retired Clerk from Assam State Electricity Board<br />Address: Doom Dooma, Dist: Tinsukia, Assam<br />Bed: 88; Unit: Male Med Unit V<br />Date of Admission: December 5th, 2008<br />Date of Examination: December 14th, 2008<br />
  3. 3. CHIEF COMPLAINS<br />Cough for last 1month<br />2. Chest pain for last 1month<br />
  4. 4. History of Present Illness: COUGH<br /><ul><li>Gradual onset, progressive
  5. 5. Harsh, forceful, wheezy and in frequent bouts
  6. 6. Persistantthro’out the day, more at night
  7. 7. Minimalmucoid expectoration with one episode of blood tinging</li></li></ul><li>History of Present Illness: COUGH<br /><ul><li>Not assocatied with
  8. 8. Profuse expectoration
  9. 9. Alteration is quality of cough
  10. 10. Fever, night sweats
  11. 11. Post nasal drip, hawking, irritation in neck
  12. 12. PND
  13. 13. Audible wheeze by the family members</li></li></ul><li>History of Present Illness: CHEST PAIN<br /><ul><li>Gradual onset, Slowly progressive, Dull aching
  14. 14. Located over anterior chest, w/o radiation or referral
  15. 15. Persistentthro’out the day , w/o any variation
  16. 16. Aggravated on coughing/deep breath w/o change in character
  17. 17. No postural, diurnal, temporal variation
  18. 18. Symptomatically improved after admission for last 5 days</li></li></ul><li>History of Present Illness: CHEST PAIN<br /><ul><li>Not associated with:
  19. 19. Sweating, palpitation, radiation to arms or neck
  20. 20. Sudden severe attacks requiring emergent care
  21. 21. Superficial skin eruptions
  22. 22. Trauma
  23. 23. Chest heaviness or tightness
  24. 24. Regurgitation of food, hawking
  25. 25. Exertionaldyspnea</li></li></ul><li>History of Present Illness: Positive History<br /><ul><li>The above symptoms were associated with:
  26. 26. Weight loss over last 1 month
  27. 27. Malaise, muscle pain, headcahe
  28. 28. Pain in the back of neck… dull aching , aggravated by extremes of movement for last 14 days
  29. 29. Mild hoarseness of voice for last 14days
  30. 30. Hospitalisation for these complains 15 days back from where he was refferred</li></li></ul><li>History of Present Illness: Negative History<br /><ul><li>There was no history of
  31. 31. Fever, recurring drenching night sweats
  32. 32. Pain abdomen,LBP,Bleeding from natural orifices
  33. 33. LOC, seizure, syncope
  34. 34. Flushing, diarrhea, skin eruptions
  35. 35. Swelling or mass in any part of body
  36. 36. Not known to be a diabetic or hypertensive</li></li></ul><li>History of Past Illness<br /><ul><li>Recurrent episodes of Malena : 4 episodes in last 35years requiring multiple hospitalisation and 2 units of Blood Transfusion
  37. 37. + H/o exposure to TB @ work place
  38. 38. No H/o TB, Jaundice, Contact, Surgery, Drugs,
  39. 39. No history of nasal polyps, allergy or hypersensitivity to dust, drugs or any other stimuli
  40. 40. No h/o of persistent cough or winter exacerbation of cough </li></li></ul><li>Personal History<br /><ul><li>Decreased appetite
  41. 41. Disturbed sleep due to nocturnal cough
  42. 42. Normal bowel & bladder habits, no c/o of hesitancy or urgency
  43. 43. Smoker; smoked for 55 years (cigarettes)
  44. 44. 110 pack years of smoking
  45. 45. Age of initiation: high school
  46. 46. Non alcoholic</li></li></ul><li>Family, Socio economic& Occupational History<br /><ul><li>All the family members are enjoying good health
  47. 47. No significant family history noted among parents and grand parents
  48. 48. Lower middle class Family
  49. 49. Discontinuous exposure to areas dealing with processing of electric cables for last 40 years</li></li></ul><li>SUMMARY OF THE HISTORY<br /><ul><li>A 68 yrs old,hindu,male,retired clerk from Tinsukia with a h/o 110 pack years of smoking presented with persistent dry cough with nocturnal exacerbation with one episode of hemoptysis and dull aching chest pain that exacerbates on coughing with weight loss,malaise, anorexia for last 1month with a backgound history of Recurent upper GI bleed requiring blood transfusion, exposure to TB, long term discontinuous exposure to cable processing industry & absence of similar illness in past, DM, HTN. </li></li></ul><li>General examination<br /><ul><li>Concious , alert , cooperative & oriented
  50. 50. Decubitus: Of choice; Facies: Normal
  51. 51. Average built, Normal nutrition
  52. 52. Weight:48 Kg, height: 154cms: BMI: 20.253
  53. 53. Tongue: Thickly coated, moist
  54. 54. Oral cavity: Poor hygeine
  55. 55. Teeth: Stained in the inner and upper surface
  56. 56. Hairs: sparse with frontal baldness
  57. 57. Nails : Yellow pigmented, deformed and thickened
  58. 58. Skin: Healthy
  59. 59. Palm & soles: normal</li></li></ul><li>General examination<br /><ul><li>Pallor: Moderate
  60. 60. Cyanosis/ Edema/ Clubbing/ Jaundice: Absent
  61. 61. Neck glands: Right supraclavicular node palpable: approx 1cm, soft, mobile, nontender, solitary: Thyroid: Not enlarged
  62. 62. JVP: Not raised
  63. 63. Pulse: 112/min;Reg, N vol, N character, Art. Wall N,No RR , RF delay, all per pulses N
  64. 64. BP: 128/76mm Hg </li></li></ul><li>General examination<br /><ul><li>Resp @: 24/min Regular, AT
  65. 65. Temp: 98.6ºF
  66. 66. Axillary & Inguinal Glands: Not significantly palpable
  67. 67. Eyes:Normal Examination</li></li></ul><li>Systemic Examination: Respiratory System<br /><ul><li>Upper Resp Tract:
  68. 68. Nostril, nasal cavity, vestibules: Normal
  69. 69. Pharynx : Normal, no congestion or drip
  70. 70. Larynx: Laryngoscopy not done
  71. 71. Ala nasi: Not working during respiration</li></li></ul><li>Systemic Examination: Respiratory System<br /><ul><li>Inspection:
  72. 72. Normal shape, no deformity
  73. 73. No focal restriction / paradoxical movement
  74. 74. Levels of shoulders: Normal
  75. 75. Noabnomal pulsation/ veins/ pigmentation
  76. 76. Puncture mark at Right 5th ICS at MAL
  77. 77. Spino scapular distance: Equal
  78. 78. Accessory muscles of resp: Not working
  79. 79. Spine: Normal curvature, No deformity
  80. 80. Overall respiratory excursion of chest: Mildly decreased</li></li></ul><li>Systemic Examination: Respiratory System<br /><ul><li>Palpation:
  81. 81. Trachea : Midline, no tracheal tug
  82. 82. Crico-sternal Distance: 4 finger breadth
  83. 83. Apex beat: Left 5th ICS in MCL, Normal, No thrill
  84. 84. No localised rise of temperature
  85. 85. Tenderness on right 5th ICS in MAL
  86. 86. Chest movement: Equal on both sides
  87. 87. Chest expansion: 1.8 cms
  88. 88. No palpable rub/ crepts/ abnormal pulsation
  89. 89. Vocal Fremitus: diminished over right 5th ICS in MAL
  90. 90. Spine: No tender points/ deformity</li></li></ul><li>Systemic Examination: Respiratory System<br /><ul><li>Percussion:
  91. 91. Normal resonant percussion note all over chest except Impaired resonance over right 5th ICS in MAL
  92. 92. Clavicular percussion: Normal
  93. 93. Sternal percussion: Normal
  94. 94. Upper border of liver dullness: Right 5th ICS in MCL
  95. 95. Tidal percussion: Normal</li></li></ul><li>Systemic Examination: Respiratory System<br /><ul><li>Auscultation:
  96. 96. Bilateral Vesicular Breath sounds except Diminished vesicular breath sounds over Right 5th & 6th ICS in MAL
  97. 97. No added sounds ( e.gCrepitations/ Rhonchi)
  98. 98. Bronchophony, Whispering pectoroloqouy, Aegophony: Absent
  99. 99. Vocal resonance: Diminished over Right 5th & 6th ICS in MAL</li></li></ul><li>Systemic Examination: Cardiovascular System<br /><ul><li>Apical impulse: Not visible
  100. 100. Apex beat: Described
  101. 101. No abnormal pulsations/ thrills/ heaves
  102. 102. S1, A2, P2: normal; No added sounds</li></ul>Systemic Examination: Gastro intestinal System<br /><ul><li>Upper GI: Described
  103. 103. Abdomen: Normal shape, contour, flanks, no venous engorgement, tenderness; Hernial sites: normal
  104. 104. No hepatosplenomegaly
  105. 105. Genitalia & scrotum: Normal</li></li></ul><li>Systemic Examination: Central Nervous System<br /><ul><li>HMF: normal
  106. 106. No cranial neurodeficit, Cranium & spine: Normal
  107. 107. No sensorymotorneurodeficit
  108. 108. Meningial & cerebellar signs: Absent</li></ul>Systemic Examination: LocomotorSystem<br /><ul><li>Normal GALS screen</li></li></ul><li>Provisional Diagnoses<br /><ul><li>A chronic inflammatory or destructive process of the lung parenchyma with focal pleural involvement suggestive of:
  109. 109. Carcinoma Lung with Ipsilateral Nodal metastasis
  110. 110. Pulmonary Tuberculosis with Pleuropulmonary adhesion & pleural thickening or encysted pleural effusion
  111. 111. Interstitial lung disease with localised pleural thickening</li></li></ul><li>Investigations: Hematology & Biochemistry<br />Date: 9.12.2008<br />Blood:<br />Hb: 9.8 gm %<br />ESR: 130 mm Aefh<br />TLC: 7800/cu.mm<br />DLC: N65 L 30 E3 M2<br />Urine:<br />Clear,Aromatic, No deposits<br />Albumin: Nil<br />Sugar: Nil<br />Epith cells: +<br />Pus cells: Nil<br />Date: 9.12.2008<br />Biochemistry:<br />Random Bl. Sugar: 93mg/dL<br />Bl. Urea: 33 mg/dL<br />Ser. Creatinine: 0.9 mg/dL<br />Urea/ Creatinine ratio: 36.9<br />
  112. 112. Investigations: ECG & Radiology<br /><ul><li>ECG: Sinus tachycardia : 108 b/m
  113. 113. Mantoux Test: Negative
  114. 114. USG Abdomen: Early Fatty Changes in Liver</li></li></ul><li>Chest X ray: as on 3.12.2009<br />Homogenous opacity in Right Mid Zone<br />Imp: <br />? Encysted effusion<br />? SOL<br />? Consolidation<br />
  115. 115. Chest X ray: as on 3.12.2009<br />
  116. 116. HRCT Thorax: as on 5.12.2009<br />
  117. 117. HRCT Thorax: as on 5.12.2009<br />
  118. 118. HRCT Thorax: as on 5.12.2009<br />
  119. 119. HRCT Thorax: as on 5.12.2009<br /><ul><li>Area of parenchymal consolidation ( 4X3.8cms) in Right Lower Lobe with subcarinalperibronchialadenopathy
  120. 120. ? Malignant Lesions
  121. 121. ? Consolidation
  122. 122. Patchy Areas of Ground glass opacities in Right lower lobe
  123. 123. Pleuropericardial&pleurodiaphragmatic adhesions in B/L bases
  124. 124. Degenerative changes of Dorsal vertebrae
  125. 125. Aortic calcifications</li></li></ul><li>CT guided FNAC : 9.12.2008<br /><ul><li>MCG Staining of the smear shows:
  126. 126. Groups of mesothelial cells with mild cellular atypia along with scattered histiocytes& multinucleated giant cells
  127. 127. No S/o Malignancy seen
  128. 128. Impression: Mesothelial Hyperplasia</li></li></ul><li>Thank You<br />

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