1601006070 LONG CASE

 

Final Exam Long 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 .


INTRODUCTION

40 year old male, labourer by occupation, resident of Narketpally came to OPD with chief complaints of

Breathlessness since 1 month

Fever since 10 days

Chest pain since 4 days


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 month back, then developed

breathlessness which was insidious onset which used to be grade 2(MMRC)  and progressed to grade 4 since in the last 4 days with no postural or diurnal variation associated with generalised weakness. It was followed by low grade fever which was on and off since 10 days  not associated with chills and rigor, shows no diurnal variation and relieved on medication, and 

Cough since 7 days, associated with moderate amount of purulent sputum mixed with saliva which is whitish in colour with no postural variation and

Chest pain on left side on inspiration and coughing since 4 days which was non radiating and relieved on lying down.

No history of palpitation, syncopal attack, haemoptysis, recurrent sore throat, hoarseness, choking episode, joint pains, burning micturition, loose stools,constipation.


PAST HISTORY

Not a Known case of DM, hypertension, epilepsy, asthma, CVD, TB, thyroid disease


FAMILY HISTORY

No history of similar complaints in family.


PERSONAL HISTORY

Diet mixed

Appetite decreased

Sleep adequate

Chronic smoker since 14yrs 16-18 beedis/day

Chronic alcoholic since 10yrs and consumes 90ml/day.

Bladder and bowel movements are regular


GENERAL EXAMINATION

Consent obtained

The patient was examined in supine and sitting position.

Patient is conscious coherent cooperative well oriented to time place and person, has  generalised wasting of muscles and is comfortable on bed.


There is no pallor, icterus, cyanosis koilonychias, clubbing, lymphadenopathy, pedal edema

JVP is not elevated, hepatojuglular reflex absent.










VITALS

Temperature : Afebrile,98 F

Respiratory rate : 40  cycles per minute

Pulse rate : 100 beats/min regular in rhythm character volume 

Blood pressure : 90/70 mmHg left arm in sitting position.

Spo2 : 98% on room air.


SYSTEMIC EXAMINATION

Respiratory system: 

1. Upper airway

Nose normal alae Nasi, septum

Oral cavity teeth pharynx normal no sinus tenderness


2. Examination of chest

INSPECTION

Shape of chest is flat

Both the shoulders appear to be at the same level

Trachea appears to be central

Apical impulse is not visible

Skin over chest is normal

Trail sign is absent 

Hollownesss in supraclavicular and infra clavicular fossae  

Movements of respiration:

Tachypnea is present and abdomino thoracic respiration


 PALPATION

- No local rise of temperature

- No tenderness

- Chest is expanding equally on both sides

- Tactile vocal fremitus is increased infra axillary, infra scapular areas left side


PERCUSSION

Direct percussion on clavicle, sternum and Manubrium is resonant 

Kronig isthmus resonant both sides

Indirect percussion(left) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-6 intercostal spaces are resonant, 5-7 intercostal spaces dull, posterity 9th intercostal space dull

Traube space is dull.


Indirect percussion(right) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-7 intercostal spaces are resonant. Posterity 9th intercostal space resonant.


AUSCULTATION

Left side infra clavicular, mammary, supra scapular,  normal vesicular breath sounds, decreased bronchial breath sounds at infra axillary, scapular, infra scapular areas. 

Crepitations at infra scapular area

Vocal resonance increased

Right side infra clavicular, mammary, supra scapular, infra axillary, infra scapular areas-vesicular breath sounds


 

Other system examination 

CNS - no facial asymmetry all reflexes are normal 

CVS- S1 S2 heard no added murmurs

ABDOMEN - abdomen is scaphoid with no organomegaly


INVESTIGATIONS:

GRBS 650 mg/dl













This could be a case 
 of diabetes mellitus and ketosis (de novo) with left lobe consolidation with chronic calcific pancreatitis 

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