1601006146 LONG CASE

 

GENERAL MEDICINE FINAL PRACTICAL 

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  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-centred 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


LONG CASE


A 14 year old male patient from Nalgonda student by occupation, came to OPD 3 days back with Chief complaints of Cough since 8 days and shortness of breath since 8 days 
Fever since 8 days

History of present illness :

Patient was apparently asymptomatic 8 days ago and then he developed fever insidious onset , Low grade, continuous associated with chills and rigors, relieved on medication

H/o SOB Since 8 days insidious onset
Progressive from MMRC grade 1 to grade 2
Increased on exertion and cough 
Relieved on sitting position, no diurnal, positional variation 
(No orthopnea and PND)


H/o of Dry Cough - since 8 days, insidious onset,  non progressive, no aggravating and relieving factors, no positional variation

Loss of appetite 
No complains of chest pain 
Burning micturition
Loss of weight
No h/o of TB


PAST HISTORY:

H/o of similar complaints since5-6 years ( on regular inhaler usage )(asthalin, bordecort) 

no history of TB, DM, Epilepsy, HTN.


PERSONAL HISTORY:

Appetite:Decreased appetite 
Diet: Mixed 
B and B - Regular
Sleep - Adequate 
No addictions

FAMILY HISTORY:
No history of similar complaints in family


GENERAL EXAMINATION:
Patient is Conscious, Coherent,Cooperative, oriented to time , place , person and comfortably lying on bed 
Moderately built and nourished
No signs of 
Pallor
Cyanosis 
Clubbing
Koilonychia 
Generalised lymphadenopathy


VITALS

Pulse : 90 beats per minute

Blood pressure:110/70 mmhg on supine position

Respiratory system-18 cycles per min

Temperature: Afebrile

SpO2-95%


LOCAL EXAMINATION OF CARDIO VASCULAR SYSTEM:

Inspection:

Shape of chest - Elliptical , Bilateral symmetrical,No deformity

Trachea position-Central , expansion of chest decreased on left side 

Apical impulse couldn't be seen
No use of accessory muscles of respiration
No Supra or infra clavicular hollowness or fullness
No drooping of shoulder
No crowding of ribs 
No wasting of muscles 

No scars ,sinuses, engorged veins.

Spine and scapula distance is increased on left side


Palpation:

No local rise in temperature and tenderness
All inspectory findings confirmed by palpation
No local rise of. Temperature
Trachea : central
Chest movements decreased on left side
Apex beat:left 5th intercoastal space.
TVF -decreased on left infra scapular ,IAA,AA.
Heart sounds:S1 And S2 hears
Murmurs: no murmurs
Pericardial rub: NO

Percussion:

Direct: Resonant 
Indirect -Dull on left infra SA and inter SA 
AA; IAA 
Liver dullness from right 5th intercostal space
Cardiac dullness within normal limit 




Auscultation:

S1 and S2 heard
Murmur absent
Bilateral air entry-Positive
Decreased breath sounds-ISA,IAA, Interscapular area
Added sounds: Absent 
Per abdomen : Soft, non tender ,no organomegaly 

CNS EXAMINATION:NAD


INVESTIGATIONS: 

Complete blood picture : Slight decrease in haemoglobin







Complete urine examination-Normal

Thoracocentesis

Pleural fluid: sugar and protein normal


















Serum electrolytes: Chloride is increased 








LFT: Total bilirubin and direct bilirubin increased 

SGPT (ALT) - Normal 
ALP- Normal 
SGOT(AST) -Normal 
















Chest X-Ray










Ultrasound: Moderate plural effusion with thin internal septations
Noted in left pleural cavity 
Passive attelectasis of lung 







Serology:

Serum LDH - Increased 
Serum RBS - Decreased 
Uric acid - Normal 
Serum protein: Decreased 
RT PCR
Sputum culture 
Ultra sound 
2D echo 

Provisional diagnosis : Left sided plural effusion 



Treatment:

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