Case presentation

Name – dhapa
Age- 61
Sex- f
Residnce- bassi
Occupation- farmer

Chief complain-
1. Shortness of breath- since 4 year
2. Cough- since 4 year
• Pt has 4 yr long H/o sob, on & off, which was increased 7 day back.
Which Gradually increased, not relieved by taking rest. Sob increase in
rainy season. Initially she walk slowly, and sob increase on walking
faster. Now she has sob only on doing strenuous exercise. Sob not a/w
fever/chest pain/ vertigo/syncope.
She has h/o occasional cough on & off since 4 year, slight decrease by
medication and reoccur. Which is occasionally productive, mucoid
sputum, in slight amount. Not a/w seasonal variation or change in
body position.
Past history-
She has h/o pulmo. TB, 4 yr back, she taken 6 month course and
completed it.
She has no h/o HTN/DM/CAD/BT
She taking medication for sob since 4 year & non compliant to rhem.
She has no h/o of any surgery.
Personal history-
Smoker, take cigar 6-7/day since 6 month
And bidi one packet /day, since 30 yr
Non alcoholic
Non vegetarian
Normal bowel/bladder/sleep

Family history- not significant

Menstrual history- menopause 15 yr back

General examination-
Conscious/oriented to TPP
Bp-130/70 mmhg in both arm in supine
Spo2- 98%
Pulse- 62/min, regular, normal volume/character, no R-R delay, no R-F
delay, all peripheral pulse palpable
Respi rate- 16/m , regular, abdo-thorasic
JVP- not distended,
Temperature- afebrile on touch
No p/i/c/c/l/e
Multiple hyperpigmented macule of 2-3 mm on upper limb and lower
limb.
Skin is dry .
Tongue is white coated from sides.
Respi system examination-
Inspection-
Breathing is abdomino-thorasic, regular.
Chest is circular, symmetrical B/L,
No scar mark,
No dilated veins,
Apex beat is visible in left side in 5th IC space, medial to MCL
Palpation-
Trachia is central
Respi movement-
Supraclavicular- restricted, B/L symetrical
Infraclavicular- restricted ,B/L symetrical
Mammalary- restricted , B/L symetrical
Supra scapular- restricted , B/L symetrical
Inter Scapular- restricted , B/L symetrical
Infrascapular- restricted , B/L symmetrical
Diameter-
Transverse- 28cm
Ap – 18cm
Chest circumference- expi- 78cm
insp- 79.5 cm
Chest expansion-1.5 cm

Rib crowding absent

Vocal fremitous-
site rt Lt
Supra clavi n Dec
Infra clavi n Dec
mammal N Dec
Axillary n n
Infra axi n n
Supra sca n n
Inter sca n dec
Infra sca n dec
• Percussion-
site rt Lt
Supra clavi hyperesonant hyperesonant
Infra clavi hyperesonant hyperesonant
clavi hyperesonant hyperesonant
mammal hyperesonant hyperesonant
Axillary hyperesonant hyperesonant
Infra axi hyperesonant hyperesonant
Supra sca hyperesonant hyperesonant
Inter sca hyperesonant hyperesonant
Infra sca hyperesonant hyperesonant

cardiac dullness in left 3rd Ic space to 6th Ic space

Liver dullness in right 7th Ic space , in MCL
auscultation-
Breath sound-
site Rt Lt
Supra clavi Broncho vascicular Broncho vascicular
Infra clavi Broncho vascicular Broncho vascicular
mammal Broncho vascicular Broncho vascicular
Axillary Broncho vascicular Broncho vascicular
Infra axi Broncho vascicular Broncho vascicular
Supra sca Broncho vascicular Broncho vascicular
Inter sca Broncho vascicular Broncho vascicular
Infra sca Broncho vascicular Broncho vascicular
Vocal resonance-
site Rt Lt
Supra clavi Equal Equal
Infra clavi Equal Equal
mammal Equal Equal
Axillary Equal Equal
Infra axi Equal Equal
Supra sca Equal Equal
Inter sca Equal Equal
Infra sca Equal Equal

Adventitious sound-
Inspiratory and expiratory, polyphonic rhonchi present all over the
chest.
Other system examination-
Cardiac- normal apical impulse, JVP not dilated, no thrill/ murmur
GI- no organomegaly/ ascities, no tenderness/ guarding
Neuro- not significant
Diagnosis-
B/L obstructive lung disease, secondary to smoking.
test 7-3-24
hb 7
lymphocyte 30%
neutrophil 56%
monocyte 10%
plat 34000
hct 25
mcv 114
Total wbc 1300
LDH 620
LFT N
RFT N
ESR 27

Usg- mild splenomegaly of 126 mm

PBF- anisopoikilocytosis, leukopenia, atypical cell 40%, ?? Blast

thrombocytopenia
Final diagnosis-
Obstructive lung disease with MDS or Acute Leukemia