54 yr old man with chest pain

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54 old man who is a dailywage labourer and construction worker  came with the c/o chest pain since 20 days. 

Chest pain since 20 days which is sudden in onset, gradually progressive, diffuse, radiating to both hands

Not associated with hemoptysis, cough, wheeze, dyspnea, fever, hoarsiness of voice, palpitations, easy fatigability, night sweats. 

Pt was apparently asymptomatic 35 yrs back then he had cough with expectoration for 2 months which is gradual in onset , worsened on lying down and releived with medication. 

He then consulted a general practitioner where he was allegedly diagnosed with pulmonary tuberculosis and took a full 6 months course of ATT. 

The pt reported a history of involuntary weight loss of approximately 20kgs when he was diagnosed with tuberculosis. 

He noted this when he felt his clothes were becoming too loose for him. The patient also reported history of loss of appetite. 

k/c/o HTN since 2 years on regular medication, TB 35 yrs back used ATT for 6months.

De novo diabetes 

Not a k/c/o asthma, epilepsy, ckd, chd. 

Personal history:

Diet- mixed

Appetite- decreased

Sleep- adequate

Bowel- regular

Bladder- increased nocturnal urinary frequency (7-8times) 

Habbits/addictions- alcoholic since 35yrs , 90-180ml/day, smoking 35 years back(40 beedis/day) for 6 - 7 years

Family history: no similar complaints in the family

General examination:

pt is conscious, coherent, cooperative, moderately build and nourished

no signs of pallor, icterus, koilonychia, cyanosis, edema

Clubbing : +

Vitals:

BP  - 120/80 mm hg rt arm ,supine position

PR - 88,regular, normal volume

Temp- afebrile

RR- 18CPM

spo2-98%

Grbs  200 mg/dl

systemic examination: 

 Respiratory: 

upper respiratory tract:

Nose - no polyps, DNS

Oral cavity- oral hygiene maintained, tonsils(normal)

 

Pharynx- post nasal drip(-) 

Inspection:

shape of the chest- ellipsoid

Respiratory movements- moving symmetrically on both sides

trachea position- central

Accessory muscles of respiration- not being used

Apical impulse- not seen

Supracalvicular hallowness - present(mild) on left side

infraclavicular hallowness- negative

Drooping of shoulder- left side present

chest deformities- ( - ) 

intercostal retraction-  2nd ICS present

Palpation:

tracheal position- central

apex beat- 5th ICS present 

Chest wall tenderness - negative

chest circumference- 37 cms

Anteroposterior diameter - 20 cms

Transverse diameter - 23cms

Chest expansion- 1cm on deep inspiration

symmetry of chest expansion- symmetrical

Vocal fremitus- increased on left posterior and lower lobes. 

Percussion: 

Anterior chest wall: 

Clavicle- resonant

supracalvicular- resonant

Infraclavicular- right side impaired resonance

Mammary- resonant

Inframammary- left side impaired resonance

posterior chest wall:

suprascapular- resonant

Interscapular- resonant

Infrascapular- left side impaired resonance

Lateral chest wall:

axillary- resonant

Infra axillary- left side impaired resonance

percussion tenderness - negative 

Auscultation:

Air entry- bilateral present

Vocal resonance- increased on left posterior and lower lobes

P/A: 

Umblicus inverted

abdomen is soft non tender

 No organomegaly

Bowel sounds heard. 

Hernial orrifices -free

CVS:

S1&S2 heard, No murmurs

CNS:

Higher mental functions  normal

Oriented to place, time, person

Speech is normal in pitch and tone

Memory: recent and remote memory intact

All cranial nerves intact

Motor:

                             Left                      Right

Bulk:

UL                          N                         N

LL                          N                         N

                          

Tone:

UL                         N                           N

LL                          N                          N

Power:

UL                         N                         N

Superficial reflexes:

                             Left                         Right

Corneal:              present                present

Conjunctival:     present                 present

Abdominal:        present                 present

Plantar:                flexor                    flexor

Deep tendon reflexes 

                                Left                       Right

Biceps                      +                            +

Triceps                     +                            +

Supinator                 +                            +

Knee                          +                            + 

Ankle:                        +                            +

   

   

Sensory:

Fine touch:               N

Crude touch:            N

Pain temp:               N

Vibration:                 N

Joint position:        N

Proprioception:      N

No cerebellar signs

Investigations

                                       RFT

                        Chest x-ray

                                FBS

                                  ESR

                           HbA1c

Treatment:

1) T. Pan 40mg OD

2) T. Amlong 5mg OD

3) T. Augmentin 625mg TID

4) T. Azithromycin 500mg OD

5) T. Dolo 650mg sos

6) T. Glimi- M1 OD

7) T. MVT OD/PO

8) T. Ultracet TID

9) Syp. Sucralfate 15ml TID

Provisional diagnosis: k/c/o pulmonary kochs(35yrs back), left lower lobe consolidation with k/c/o HTN since 2 yrs, de novo diabetes.