Case presentation on panel discussion

1. CASE PRESENTATIONonRespiratory Medicine Moderator: Dr. B. Laskar Professor & Head The Department of Medicine Assam Medical College & Hospital Dibrugarh Presenter: Tanoy Bose Post Graduate Trainee Department of Medicine Assam Medical College & Hospital

2. PATIENT PARTICULARS KHAGEN BARUAH 68 years; Male; Hindu Retired Clerk from Assam State Electricity Board Address: Doom Dooma, Dist: Tinsukia, Assam Bed: 88; Unit: Male Med Unit V Date of Admission: December 5th, 2008 Date of Examination: December 14th, 2008

3. CHIEF COMPLAINS Cough for last 1month 2. Chest pain for last 1month

5. Harsh, forceful, wheezy and in frequent bouts

6. Persistantthro’out the day, more at night

8. Profuse expectoration

9. Alteration is quality of cough

10. Fever, night sweats

11. Post nasal drip, hawking, irritation in neck

12. PND

14. Located over anterior chest, w/o radiation or referral

15. Persistentthro’out the day , w/o any variation

16. Aggravated on coughing/deep breath w/o change in character

17. No postural, diurnal, temporal variation

19. Sweating, palpitation, radiation to arms or neck

20. Sudden severe attacks requiring emergent care

21. Superficial skin eruptions

22. Trauma

23. Chest heaviness or tightness

24. Regurgitation of food, hawking

26. Weight loss over last 1 month

27. Malaise, muscle pain, headcahe

28. Pain in the back of neck… dull aching , aggravated by extremes of movement for last 14 days

29. Mild hoarseness of voice for last 14days

31. Fever, recurring drenching night sweats

32. Pain abdomen,LBP,Bleeding from natural orifices

33. LOC, seizure, syncope

34. Flushing, diarrhea, skin eruptions

35. Swelling or mass in any part of body

37. + H/o exposure to TB @ work place

38. No H/o TB, Jaundice, Contact, Surgery, Drugs,

39. No history of nasal polyps, allergy or hypersensitivity to dust, drugs or any other stimuli

41. Disturbed sleep due to nocturnal cough

42. Normal bowel & bladder habits, no c/o of hesitancy or urgency

43. Smoker; smoked for 55 years (cigarettes)

44. 110 pack years of smoking

45. Age of initiation: high school

47. No significant family history noted among parents and grand parents

48. Lower middle class Family

50. Decubitus: Of choice; Facies: Normal

51. Average built, Normal nutrition

52. Weight:48 Kg, height: 154cms: BMI: 20.253

53. Tongue: Thickly coated, moist

54. Oral cavity: Poor hygeine

55. Teeth: Stained in the inner and upper surface

56. Hairs: sparse with frontal baldness

57. Nails : Yellow pigmented, deformed and thickened

58. Skin: Healthy

60. Cyanosis/ Edema/ Clubbing/ Jaundice: Absent

61. Neck glands: Right supraclavicular node palpable: approx 1cm, soft, mobile, nontender, solitary: Thyroid: Not enlarged

62. JVP: Not raised

63. Pulse: 112/min;Reg, N vol, N character, Art. Wall N,No RR , RF delay, all per pulses N

65. Temp: 98.6ºF

66. Axillary & Inguinal Glands: Not significantly palpable

68. Nostril, nasal cavity, vestibules: Normal

69. Pharynx : Normal, no congestion or drip

70. Larynx: Laryngoscopy not done

72. Normal shape, no deformity

73. No focal restriction / paradoxical movement

74. Levels of shoulders: Normal

75. Noabnomal pulsation/ veins/ pigmentation

76. Puncture mark at Right 5th ICS at MAL

77. Spino scapular distance: Equal

78. Accessory muscles of resp: Not working

79. Spine: Normal curvature, No deformity

81. Trachea : Midline, no tracheal tug

82. Crico-sternal Distance: 4 finger breadth

83. Apex beat: Left 5th ICS in MCL, Normal, No thrill

84. No localised rise of temperature

85. Tenderness on right 5th ICS in MAL

86. Chest movement: Equal on both sides

87. Chest expansion: 1.8 cms

88. No palpable rub/ crepts/ abnormal pulsation

89. Vocal Fremitus: diminished over right 5th ICS in MAL

91. Normal resonant percussion note all over chest except Impaired resonance over right 5th ICS in MAL

92. Clavicular percussion: Normal

93. Sternal percussion: Normal

94. Upper border of liver dullness: Right 5th ICS in MCL

96. Bilateral Vesicular Breath sounds except Diminished vesicular breath sounds over Right 5th & 6th ICS in MAL

97. No added sounds ( e.gCrepitations/ Rhonchi)

98. Bronchophony, Whispering pectoroloqouy, Aegophony: Absent

100. Apex beat: Described

101. No abnormal pulsations/ thrills/ heaves

103. Abdomen: Normal shape, contour, flanks, no venous engorgement, tenderness; Hernial sites: normal

104. No hepatosplenomegaly

106. No cranial neurodeficit, Cranium & spine: Normal

107. No sensorymotorneurodeficit

109. Carcinoma Lung with Ipsilateral Nodal metastasis

110. Pulmonary Tuberculosis with Pleuropulmonary adhesion & pleural thickening or encysted pleural effusion

113. Mantoux Test: Negative

115. Chest X ray: as on 3.12.2009

116. HRCT Thorax: as on 5.12.2009

117. HRCT Thorax: as on 5.12.2009

118. HRCT Thorax: as on 5.12.2009

120. ? Malignant Lesions

121. ? Consolidation

122. Patchy Areas of Ground glass opacities in Right lower lobe

123. Pleuropericardial&pleurodiaphragmatic adhesions in B/L bases

124. Degenerative changes of Dorsal vertebrae

126. Groups of mesothelial cells with mild cellular atypia along with scattered histiocytes& multinucleated giant cells

127. No S/o Malignancy seen