CASE PRESENTATION :

MODERATORS:

DR. P. DHURVEY (MD)

DR. K.DEOPUJARI(MD)
DR.A.SEJWAR(MD)
PRESENTED BY
Dr . Arvind kumar
RMO III
Dr.Satish Badavat
RMO III
Dr.Sourabh
RMO

I
 PATIENT DETAILS

 NAME- Geeta sahu

 AGE/ SEX- 30/Male
 RESIDENT OF – gram kheri ,tehsil –silwani , raisen
 OCCUPATION- house wife
 EDUCATION -
 Referred from TB and chest hospital and Admitted in Hamidia Hospital on
27Sept 2022 in unit 2 under general medicine.
 CHIEF COMPLAINTS

1)Cough with expectoration since 1 month

2) Difficulty in breathing since 15 days
 HISTORY OF PRESENT ILLNESS

1)My patient was apparently alright 1 months ago, after which she
started having cough, which was, insidious in onset and gradually
progressive in the form of increased frequency of coughing. Cough
occurred multiple times in a day, but there was no diurnal
variation .the cough was productive in nature which was white in
colour and later on it converted into yellowish colour with thick in
consistency . previously the sputum was non smelly but later on it
became foul smelling which started to irritate the patient and there is
h/o increased amount of sputum after getting up from left decubitus
position and starts coughing .
Cough has persisted for around 1 months so far.
Cough was not associated with any audible
wheezing. There is no history of dripping
sensation in the throat or recurrent throat
clearing or nasal congestion or nasal discharge.
There is no history of blood in sputum. Patient
has taken some cough syrup for the same,
however there has not been complete resolution
even after that.
 HOPI conti..

2)Patient is house wife by occupation and after 15

days she started experiencing difficulty in breathing
which was gradual in onset and progressive in nature
while doing her daily activities in the form of unable
to climb stairs which she was previously able to do
without any difficulty and after which she use to
clean all the house by herself and now she use to
clean in intervals since she use to get breathless while
cleaning which got relieved by stopping for a while
and stand still and catch her breath.
HOPI conti..

After 1 week She also started having difficulty in

cooking food which she was previously able to make
within 1 hour now she takes 2-3 hrs to make food
due to breathlessness during making chapatis .after a
4-5 days she started walking at a slower pace due to
increase in the symptoms while walking at the
previous ordinary pace .she also use to work in
paddy field and was able to walk more than 500
meters but now she gets breathless on walking even
for 100 meters (MMRC GRADE 3).
HOPI conti..
After 2 days she started having breathlessness on supine
position for which she use to sleep in left lateral decubitus
position but after a while her breathlessness use to
aggravate on this side also and also was associated with
increased cough and foul smelling sputum production
after which she then started sleeping in right decubitus
position comfortably .
There is no history of chest pain while breathing on any
decubitus position .
There is no history of orthopnea or PND .
No history of pedal edema or any swelling
No h/o palpitations .
There is no history of fever .
HOPI conti..

Due to breathlessness she was hospitalised in a

nearby hospital where, according to patient’s
attendant different investigations like chest
xray ,sputum examination and ct scan of chest
along with some blood investigations was done
after which patient was referred to TB and chest
hospital ,bhopal.
Currently there is decreased episodes of cough
and foul smelling sputum was resolved after
receiving medications from the ward .
 PAST HISTORY

History of ATT intake for pulmonary tuberculosis

on radiological basis 15yrs back for 9 months .
Icd was placed 15 yr back.

No h/o HTN /DM /Bronchial asthma

 PERSONAL HISTORY:

Diet – pure vegetarian

Appetite – decreased.
Sleep – decreased due to night time awakening due
to increased episodes of cough .
Bladder – normal
Bowel habits – normal
Socioeconomic scale –
 score 9 (Upper lower class )
 FAMILY HISTORY:

No history of tuberculosis in the family

 Summary after History
 30 year old female , housewife by occupation presented with chief
complaints of cough since 1 month which was productive and foul
smelling with thick in consistency and white in colour and
breathlessness since 15 days progressing from MMRC GRADE1 
MMRC GRADE 3 with more comfortable in right decubitus position
than left with past history of pulmonary tuberculosis 20 yrs back is
most llikely suffering from ;
 Organ system involved- respiratory system
 Anatomical involvement – parenchyma >> pleura
 Pathology- right pleural effusion >> post TB bronchiectasis
 Etiology- infective ? Reactivation of P.Tuberculosis (post tubercular
sequalae)
 General physical examination.

 Patient is conscious , cooperative and well oriented to time ,place and person.
 Decubitus- sitting
 No pallor, clubbing, icterus, cyanosis, lymphadenopathy, pedal edema.
 Built- thin, nutrition - poor
 Weight- 40 kg
 Height- 158 cm
 BMI : 16 kg/m2
 Afebrile
 Pulse : 90 /min in right radial artery; regular rhythm,With normal volume .
 Bp- 110/70 mm hg right brachial artery in sitting position with mercury
sphygmomanometer.
 RR- 18 /min thoraco-abdominal.
 Spo2- 96 % on room air
 Systemic examination:
Uppper Respiratory tract infection :
Upper respiratory tract-

Nasal cavity : normal , no nasal flaring noted

No deviated nasal septum, no nasal polyp

Oral cavity- poor oral hygiene

Pharynx - WNL
 Inspection

Chest
 wall asymmetrical.
Trachea shifted
 to right side (trail sign positive )
Chest
 movement decreased on right side
Drooping
 of shoulder present on right side
Supraclavicular
 hollow seen on both side (right >> left )
Scar mark
 seen in right axillary area .
Apical
 impulse not seen .
Breast
 are assymetrical and level of right nipple is lower than left side .
No kyphoscoliosis.
No dialated vein seen .
 Palpation

Local temperature not raised

No intercostal tenderness
Trachea shifted to right side, Trail sign positive
Apex beat palpated at left 5 th ICS half inch medial
to midclavicular line
Chest movements decreased on right side
Rib crowding present in infra axillary area.
 MEASUREMENTS

Total chest circumference :70 cm after full expiration

 71.5 cm after full inspiration
 Chest expansion : 3 cm
 Left hemithorax: 37 left chest expansion- 2.5 cm
Right hemithorax: 34 right chest expansion-0.5 cm.
Anterior posterior diameter :16
Transverse diameter : 26
AP:T ratio- 0.60 (n =0.6)
 VOCAL FREMITUS

RIGHT LEFT
SUPRACLAVICULAR INCREASED NORMAL
INFACLAVICULAR INCREASED NORMAL

MAMMARY DECREASED NORMAL

AXILLARY DECREASED NORMAL

INFRA AXILLARY DECREASED NORMAL

SUPRASCAPULAR INCREASED NORMAL

INTERSCAPULAR INCREASED NORMAL

INFRASCAPULAR DECREASED NORMAL

 Percussion
KRONIG’S ISTHMUS PERCUSSION- dull on right side
SHIFTING DULLNESS- absent
RIGHT LEFT
SUPRACLAVICULAR DULL RESONANT

CLAVICULAR DULL RESONANT

INFRACLAVICULAR DULL RESONANT
MAMMARY DULL CARDIAC DULLNESS
INFRAMAMMARY STONY DULL RESONANT

AXILLARY STONY DULL RESONANT

INFRAAXILLARY STONY DULL RESONANT

SUPRASCAPULAR DULL RESONANT

INTERSCAPULAR DULL RESONANT

INFRASCAPULAR STONY DULL RESONANT

 AUSCULTATION
RIGHT LEFT

SUPRACLAVICULAR BRONCHIAL VESICULAR

INFACLAVICULAR BRONCHIAL VESICULAR

(CAVERNOUS)
MAMMARY ABSENT VESICULAR

INFRAMAMMARY ABSENT VESICULAR

AXILLARY ABSENT VESICULAR

INFR AXILLARY ABSENT VESICULAR

SUPRASCAPULAR BRONCHIAL VESICULAR

INTERSCAPULAR BRONCHIAL VESICULAR

INFRASCAPULAR ABSENT VESICULAR

 VOCAL RESONANCE
RIGHT LEFT
SUPRACLAVICULAR INCREASED NORMAL

INFACLAVICULAR INCREASED NORMAL

MAMMARY ABSENT NORMAL

AXILLARY DECREASED NORMAL

INFRA AXILLARY DECREASED NORMAL

SUPRASCAPULAR INCREASED NORMAL

INTERSCAPULAR INCREASED NORMAL

INFRASCAPULAR DECREASED NORMAL

AEGOPHONY : PRESENT
SUCCUSSION SPLASH : ABSENT
WHISPERING PECTORALICHY : ABSENT
OTHER SYSTEMS-
1)CARDIOVASCULAR SYSTEM – S1 S2 PRESENT, NO
MURMUR HEARD .

2) PER ABDOMEN – SOFT , NON TENDER, NOT

DISTENDED.
NO ORGANOMEGALY

3) CNS- CONSIOUS, ORIENTED AND COOPERATIVE WITH

TIME , PLACE AND PERSON
 SUMMARY AFTER EXAMINATION

30 year old female presenting with cough with foul smelling sputum production

since 1 month and breathlessness for 2 weeks which improved with sleeping in right

decubitus position with trachea shifting to right side, decreased right hemithorax

movement ,drooped right shoulder, right supraclavicular hollowing,flattening of

right infraclavicular region, rib crowding present in right upper chest till 3 rd ICS,

apex medial to left mid clavicular line , Tactile vocal fremitus and vocal resonance

increased in right suprascapular, interscapular , supraclavicular, and infraclavicular

region and decreased in rest of the regions in the right side and normal on left side.

dull note on percussion on right suprascapular, axillary, supraclavicular, clavicular

and infraclavicular region and stony dullness on rest of the regions in right side and

resonant note on left side.

Bronchial breath sound (cavernous)on right suprascapular,
supraclavicular, and infraclavicular region and absent breath sounds in
rest of the region in right side with normal vesicular breath sound in all
regions of left lung is most likely suffering from-
 Anatomical involvement : right lung parenchyma, pleura

 Pathology- right upper lobe lung volume loss(collapse/fibrosis) ?

secondary to bronchial obstruction with cavity with right pleural

effusion?tubercular
 Etiology - ? Post tuberculosis sequale
THANK YOU