CASE -6

A 50 years old patient of farmer in occupation and resident of nalgonda came to hospital with complaints of cough and fever 
CHEIF COMPLAINTS:
Fever since 1 week
Cough associated with sputum since 4 days 
HOPI:
Patiemt was asymptomatic 1 week back then developed fever which was low grade,not associated with chills, and there was nocturnal rise in temperature noted. The cough was insideous in onset,gradually progressive and was associated with sputum and with blood occassionally.
No complaints of 
VOMITING 
Burning micturation
Constipation
Pain in the abdomen 
PAST HISTORY: 
H/o
* RTA 3 years ago in which implantaion was done in left hip.
* DM TYPE-2 since 2 years for which he was on TAB GLIMI-P 60 mg
NO H/O
Epilepsy
Blood transfusions
Thyroid disorders
Asthama
HTN
CAD
PERSONAL HISTORY:
Appitite is normal
Mixed diet
Bowel and bladder movements are normal
No known Allergies
ADDICTIONS:
Alcohol - regularly consumes 3-4 units of whiskey daily since 15 years after work
Tobacco- daily smokes 1 cigar since 10 years
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
patient was
Conscious, coherant and well co operative
Moderately built and nourished
No 
Icterus
Pallor
Lymphadenopathy
Cynosis
Pedal edema
VITALS:
Temp- Febrile
B.p- 100/80
Pulse-106
Respiratory rate- 24
RESPIRATORY SYSTEM EXAMINATION:
Chest is symmetrical 
Trachea is central in line
No signs of dypnoea
Breath sounds are vesicular
Fine Crackling sounds was heard on both expiration and inspiration 
CVS EXAMINATION:
S1 AND S2 HEARD
NO CARDIAC MURMURS
ABDOMIMAL EXAMINATION:
Abdomen is non tender
No palpable mass
No hernial orifaces
No fluid trill
CNS EXAMINATION:
No muscle wasting was noted.
INVESTIGATIONS:
Hemigram is suggested 


PROVIONAL DIAGNOSIS:
Milliary TB.









 






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