1601006028 SHORT CASE

 

1601006028 :-SHORT CASE


Hall ticket no.1601006028

General medicine :-SHORT CASE 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

 Case:
-A 51 year old male patient resident of Miryalguda , farmer by occupation ,presented with a chief complaint of  

1. Fever  since 10 days 

2. Cough  with sputum since 10 days 

3. Shortness of breath since 7 days 



-History of present illness:

Patient was apparently asymptomatic 10 days back then developed following symptoms 

Fever which was insidious in onset and it was associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication 

He then developed  Cough which  gradually progressed more during the nights and associated with sputum. It aggrevated  during exposure to colder climates .The sputum was scanty and yellow which was non foul smelling (most probably bacterial infestation).

Cough was associated with Chest pain  which was non radiating in nature and aggrevated on lying down relieved on sitting upright 

He later developed Dyspnea which went on to interfere his daily activities  Grade 3 according to MMRC.

-Past history 

-No history of Asthma ,Diabetes Mellitus ,Hypertension ,Epilepsy ,siezures
 TB : 5 yrs back and was treated with anti tubercular drugs.

-Family history-Not relevant 

-Personal history :
Appetite-normal
Sleep: inadequate 
Bowel and bladder- regular
Diet: Mixed
No food or drug allergies 
Addictions : smoking  since 40 yrs ( 3 to 4  cigarettes a day,smoking index-(no.of cigarette*years) -3*40-120.Pack years-6

-Differential Diagnosis
Pneumonia 
TB
COPD 

-General Examination :
Patient was conscious coherent and cooperative 
 undernourished,under built

-Vitals 

Pulse- 84 bpm, Regular ,Normal volume 
Bp -100/70 mm hg
Respiratory rate -24 cpm 

-On physical examination 
There is no Pallor
                     Icterus 
                     Cyanosis 
                     Clubbing 
                      Lymphadenopathy
                      Edema 
Systemic examination 
RESPIRATORY 
-Upper respiratory tract examination 

Nostrils : Normal
Nasal septum: No deviated nasal septum
Nasal polyps: No nasal polyps
Tonsils :No enlarged tonsils
Posterior pharyngeal wall appears to be normal

-Inspection of chest

Shape and symmetry :Elliptical and symmetrical 

Spine: central
Trachea :central in position
Respiratory movements -  decreased on both sides
Breathing pattern - normal
No visible pulsations 
No visible scars or sinuses

PALPATION OF CHEST
- Spine is central
-Trachea  is central 

-Dimensions AP 16.5 cm
                    Transverse 23.5 cm

-Chest expansion -decreased 


-Vocal fremitus -was increased on left infra clavicular and mammary area

-Apex beat was felt on 5 th intercostal space medial to Mid clavicular line

PERCUSSION OF CHEST

-On purcussion dull note was heard on 
-Left infra clavicular
-Left  mammary 
-Left infra scapular

AUSCULTATION ON CHEST

-bronchial breath sounds are heard

-There was an Increased  vocal resonance and crepitations on left infra clavicular and mammary area.

CVS :
Normal S1 S2 heard 
No murmurs
Apex beat felt on 5 th intercoastal space 

CNS:No focal deficits seen

INVESTIGATIONS



Provisional diagnosis-
Consolidation in the left apical region Probably due to exacerbated COPD with infective etiology

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