Case Presentation Respiratory System

Case Discussion
Subject : Medicine
Presented by students of 8th Semester MBBS

Krishnakshi Bhuyan (05)
Shreya Chetri (06)
Angshumita Baishya (07)
History :
A case was selected from Bed S68 of Medicine Unit III of AMCH
Patient's particulars:
•Name : Arun Boniya

•Age : 33 years
•Sex: Male
•Address : Namrup, Dibrugarh
•Religion: Hindu
•Educational status: Up to 9th standard
•Occupation : Unemployed but previously involved in business
(shopkeeper)
•Marital status: Unmarried
•Date of Admission : 22/6/2022
•Date of Examination : 23/6/2022
 Chief Complaints
 1) Fever for 20 days

 2) Cough for 20 days
 3) Chest pain in the left side for 15 days
 4) Difficulty in breathing for 7 days
 HISTORY OF PRESENT ILLNESS
On elaboration of the Chief Complaints, The patient complains of daily

episodes of fever for the last 20 days, which was insidious in onset and
was non progressive . The fever is low grade and intermittent in nature
and there is daily rise and fall of temperature, with a slight rise in the
evening. It subsides completely with medication and sometimes
spontaneously as well. The fever was also associated with generalized
weakness for the same duration. It was not associated with any chills,
rigor, headache, vomiting, altered behavior or abnormal body
movements. The patient did not complain of a running nose, sore
throat, pain abdomen, joint pain, rash or burning micturition.
 The patient also complains of cough for the last 20 days. It was
insidious in onset and gradually progressive in nature. The cough
was non productive and came in small bouts lasting for 2-3 min.
There were no specific aggravating or relieving factors and had no
diurnal and postural variation. There is no history of seasonal
variation of cough. There is no history of coughing of blood. There is
no associated lower limb swelling.
 The patient also complains of chest pain on the left side for 15 days.
The onset was insidious and gradually progressive in nature. It was
localized, sharp and stabbing in character. It does not radiate to any
other site. It is aggravated by deep breathing and coughing. It is
relieved to some extent by lying on left lateral position that he now
assumes all the time. For the past one week, the localized chest pain
has been replaced by a constant dull discomfort..
 The patient complains of difficulty in breathing for 7 days, which
was insidious in onset and gradually progressive in nature. Initially
he had developed difficulty in breathing only on doing strenuous
activities like lifting and carrying heavy buckets of water for a
distance but has now developed difficulty even while hurrying on
level ground . Such episodes last for about 5 to 10 minutes and
usually subsides on rest. The difficulty increases on lying down in
right lateral position and subsides on lying in the left lateral
position. It has no postural variation. It has no diurnal or seasonal
variation. There is no associated wheeze or hoarseness.
 There is history of loss of appetite and loss of weight which is

evident from loosening of his clothes. Sleep habits, bowel, bladder
habits are normal.
 COURSE DURING HOSPITAL STAY : The patient’s symptoms of
breathlessness and cough have reduced significantly and the patient is
stable, and on medication.
 PAST HISTORY : There is no history of any similar illness in the past. There
is no history of contact with patient of tuberculosis. There is no history of
Tuberculosis, Diabetes, Hypertension, COPD, asthma, recurrent
respiratory tract infections any other major illness or trauma in the past.
There is no history of high risk behaviour, IV drug abuse.
 There is no history of recent hospitalization or mechanical ventilation and
blood transfusions
 PERSONAL HISTORY :The patient is a non-vegetarian and consumes an
average Assamese rice based diet 3 times daily.The patient is a non smoker
and non alcoholic. He occasionally takes tobacco and chews betel nut.

 FAMILY HISTORY: The patient lives with his sister and her husband. There is
no similar complaints in any of the family members. There is no history of
tuberculosis, bronchial asthma, allergic disorder or malignancy in the
family. All are in good health.

 OCCUPATIONAL HISTORY: The patient is currently unemployed and
was earlier working as a shopkeeper. He was not associated with
farming activities or work in factories/ mines.
 SOCIO-ECONOMIC HISTORY: The patient belongs to a low middle
class family with per capita income of Rs 1800 per month. He lives
in a pucca house consisting of 4 rooms and separate kitchen and
uses LPG as fuel. He drinks water from tube well after filtration and
use a sanitary latrine.
 ALLERGIC HISTORY: The patient is not allergic to known inhalant,

ingestant or contactant till date.
 MEDICATION HISTORY: The patient is not on any kind of

medication.
 IMMUNIZATION HISTORY: The patient couldn’t specify his

immunization status and the BCG scar was not seen on the lateral
side of left upper arm. He has taken one dose of the Covid vaccine.
GENERAL EXAMINATION
 Consciousness: alert, conscious, cooperative and well oriented
to time, place and person .
 Appearance : The patient looks ill.
 Facies: Normal
 Decubitus: The patient is comfortable in left lateral position
 Built: average
 Nutrition: fair .
BMI =20.21 kg/m2
(height = 1.68m & weight=57kg)
Waist circumference =32 inch
 Hair and skin: Normal lustrous hair with age related graying .
Skin on the upper left lateral side of the chest has lesions.
GENERAL EXAMINATION (continued)
• Icterus: absent
 Pallor: absent
 Cyanosis: absent
 Condition of mouth and oral cavity: teeth and gums healthy. Tongue is pink moist
and normal papilla is seen.
 Condition of nose : normal; para nasal sinuses: non tender
 Neck Vein: neither engorged nor pulsatile
 Jugular Venous Pulse (JVP): Normal
 Neck glands: not palpable
 Lymph nodes: not palpable
 Clubbing: absent
 Koilonychia: absent
 Oedema: absent
 Dehydration:Absent
GENERAL EXAMINATION
(continued)
VITALS:
 Respiratory Rate:
21/ min, regular in rhythm, and abdomino-thoracic type
Accessory muscles of respiration are working.
 Blood Pressure:
110/80 mmHg in right upper arm in supine position
 Pulse:
70 beats per min
Regular in rhythm
Normal in volume and character
Condition of the arterial wall is normal.
No radio-radial and radio-femoral delay found
All other peripheral pulses are bilaterally and symmetrically
palpable
 Temperature: mildly raised to touch.
 EXAMINATION OF RESPIRATORY SYSTEM
INSPECTION
 Shape and size of chest : Normal

 Symmetry : generalised bulge present on the left side
 Movement of chest with respiration : diminished on the
left side
 Supraclavicular fossa : normal
 Position of trachea : Present at midline with no gross
deviation.
 Use of accessory muscle present during breathing
 Fullness of intercostal space is present on the left side.
 Intercostal suction absent
 No visible pulsations and dilated veins seen.
 Shoulder drooping : presence of drooping of the right
shoulder.
 Angle of scapula is normally placed.
 Kyphosis and scoliosis absent.
 PALPATION
 Trachea : is shifted to the right side

 Apex beat : is localised in the 5th ICS 1.25cm medial to the mid-clavicular line
,normal in character.
 No local rise of temperature or tenderness is present.
 Movement of the chest wall is diminished on the left side and normal on the right
side.
 Chest expansion : is 2cm at the level of the nipple.
 Vocal fremitus :
 Left side – diminished on the inframammary ,infra axillary and infra scapular
region.
 Right side – Normal.
 AP:Transverse diameter 5:7
 PERCUSSION
1) Stony dullness is present on the left side of the chest, from
4th intercostal space along the mid clavicular line,from 6th
intercostal space along the mid axillary line and on the back
in the interscapular and infrascapular areas which alter with
change of position, i.e. , shifting dullness is present.
2) Traube’s space is dull on percussion.
3) Tenderness is absent while percussing the chest.
4) On right side, normal resonant note is heard all over the
chest.
5) Kronig’s isthmus is bilaterally normal i.e. a resonance band
of 7 cm is felt.
6) Tidal percussion is normal.
7) Hepatic dullness is present from the right 5th intercostal
space.
 AUSCULTATION
 1) Diminished vesicular breath sounds on the left

side of the chest.
 2) Normal vesicular breath sounds over right side of
chest.
 3) Vocal resonance is diminished on left side.
 4)Vocal resonance is normal over the right side.
 5) No adventitious or added sounds
(crepitations,wheeze,pleural rub) heard on both
sides of the chest.
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
 Inspection :Precordium is normal :No visible pulsation or

engorged veins seen.
 Palpation: Apex Beat : is localised in the left 5th ICS 1.5 cm
outside midclavicular line, normal in character.
 No thrill or parasternal heave is felt.
 Auscultation:First and second heart sounds are heard normally
No adventitious sounds or murmur heard.
 Examination of the abdomen
Inspection:
Shape and size of abdomen is normal.
No visible pulsation and scar mark present.
Umbilicus is inverted and in the midline.
Hernial sites are intact
Palpation:
Superficial Palpation-
No raised temperature ,No tenderness, no palpable lump.
Deep Palpation- Liver-Not palpable
Kidney- Not palpable
Spleen- Not Palpable
 EXAMINATION OF THE NERVOUS SYSTEM
 Examination of Central Nervous System

 Higher function tests: Patient is conscious, alert, cooperative
and well oriented to time, place and person.
 Cranial Nerves: All cranial nerves are intact.
 Motor system: Tone and power of the muscle in all the four
limbs are normal.
 Sensory system: Superficial, deep and corneal sensations are
normal.
 Reflexes: All the superficial and deep reflexes are normal.
 Examination of the Peripheral nerves:
 There is no nerve thickening, nerve tenderness or motor
dysfunction.
 Summary of the case
 A 33 year old male presented with the chief complaints of intermittent

fever with evening rise and non productive cough for 20 days, with sharp
non radiating left sided chest pain for 15 days and progressive
breathlessness for 7 days from mMRC grade 0 to grade 1 with slight relief
on lying down in left lateral position, along with weight loss with no
history of lower limb swelling, orthopnea or PND . On examination there
was diminished chest movement, diminished vesicular breath sounds and
vocal resonance on the left side and stony dullness was felt on left side
upon percussion is probably a case of left sided pleural disease, of
tuberculous origin.
 Provisional Diagnosis
On the basis of detailed history and clinical examination, the patient is

provisionally diagnosed to be a case of left sided Pleural effusion which is
probably tuberculous in origin without respiratory failure and absent cor
pulmonale.
 INVESTIGATIONS
 Blood examination: TC, DLC, ESR, PPBS, Serum Amylase

 Chest Xray : PA view and Lateral view
 Diagnostic Pleural tapping: diagnosis, nature of fluid, smear
examination, culture, other tests
 Sputum examination :for AFB
 Mantoux test
 Imaging: USG, CT SCAN or MRI
 Pleural biopsy
 Serological tests
 DIFFERENTIAL DIAGNOSIS
 1.Pyothorax
 2.Hydrothorax
 3. Chylothorax
 4. Haemothorax
 5. Lung malignancy
 6. Consolidation with effusion
 7.Collapse with effusion
 8.Fibrosis with effusion

Case Presentation Respiratory System

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Case Discussion

Presented by students of 8th Semester MBBS

•Name : Arun Boniya

 1) Fever for 20 days

On elaboration of the Chief Complaints, The patient complains of daily

 There is history of loss of appetite and loss of weight which is

 ALLERGIC HISTORY: The patient is not allergic to known inhalant,

 MEDICATION HISTORY: The patient is not on any kind of

 IMMUNIZATION HISTORY: The patient couldn’t specify his

 Appearance : The patient looks ill.

 Decubitus: The patient is comfortable in left lateral position

 Shape and size of chest : Normal

 Trachea : is shifted to the right side

 1) Diminished vesicular breath sounds on the left

 Inspection :Precordium is normal :No visible pulsation or

 Examination of Central Nervous System

 A 33 year old male presented with the chief complaints of intermittent

On the basis of detailed history and clinical examination, the patient is

 Blood examination: TC, DLC, ESR, PPBS, Serum Amylase

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