1601006037 SHORT CASE

 

Short case

14yr old male who is a student resident of Nalgonda came with chief complaints of -

1)Fever since 8days

2)Cough since 8days

3)Shortness of breath since 8days

History of present illness :

Patient was apparently asymptomatic 8 days back then 

- He developed fever,insidious in onset, continuous,low grade associated with chills and rigor and relieved on medication

- History of cough which was insidious in onset ,not associated with expectoration and no aggravated and relieving factors.

- History of shortness of breath,which is insidious in onset,progressed from grade1 to grade 2 (MMRC),aggravated on exertion and relieved on sitting position.

RESPIRATORY SYSTEM EXAMINATION :

Inspection :

-Trachea central

-Expansion of chest decreased on left side

Palpation:

-Trachea central in position

-Expansion of chest decreased on left side

-Vocal fremitus  diminished in Interscapular , infrascapular ,infraaxillary on left side.

Percussion :

-Dull note on left Interscapular , infrascapular , infraaxillary area on left side.

Auscultation:

- diminished breath sounds on left side

- diminished vocal resonance in left infrascapular area, infraaxillary area and Interscapular area

Investigations :

Chest X ray

Provisional diagnosis:

 Left sided pleural effusion