1601006088 SHORT CASE

 

HT no: 1601006088 - SHORT CASE



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CASE : 
     A 14 year old male, who is a student, resident of nalagonda, came with chief complaints of 
    - fever since 8 days 
    - cough since 8 days 
    - shortness of breath since 8 days 

History of present illness:
       Patient was apparently asymptomatic 8 days ago then 
      - he developed fever, which was insidious in onset, low grade, continuous, associated with chills and rigors and relieved on medication
      - history of cough, which was insidious in onset not associated with expectoration and no aggravating or relieving factors. 
      - there is history of shortness of breath, which is insidious in onset, progressed from grade 1 to grade 2 ( according to MMRC ), aggravated on exertion and relieved on sitting position. 

Respiratory System examination: 

INSPECTION:
- Trachea in Central position 
- Expansion of chest decreased on left side 

PALPATION: 
- Trachea in Central position 
- Expansion of chest decreased on left side 
- Vocal fremitus diminished in interscapular, infrascapular, infra axillary on left side 

PERCUSSION: 
- Dull note on left infrascapular, infra axillary, interscapular area

AUSCULTATION:
- Diminished breath sounds on left side 
- Diminished vocal resonance in left infrascapular, infra axillary and interscapular areas 

INVESTIGATIONS:
 Chest X ray 
 



PROVISIONAL DIAGNOSIS:
      Left sided pleural effusion 

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