1801006099 short case
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I have 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 35 year old female,resident of miryalguda,worker in steel shop,came with chief complaints of shortness of breathe since 8days
HOPI:She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigo rar,for which she went near local RMP and took injections and temperature decreased.
And then she developed breathlessness 8 days back,which was insidious in onset,gradually progressive,SOB is of grade 2 i.e when climbing stairs.SOB aggravated on exposure to dust and cool air,seasonal variation is present.
History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.
History of chest pain since 8days,which is stabbing type,radiating from left lower rib upward to back.
No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.
No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss
PAST HISTORY:
She is a known case of Asthma since 6years, which was aggravated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.
She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.
She is not a known case of DM,HTN,TB,Epilepsy,CAD.
She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.
PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal
Sleep: decreased since 8days d/t chest pain.
Bowel,bladder:regular movements.
No addictions.
FAMILY HISTORY:No significant family history.
Not allergic to any drugs.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,edema appears on long standing and decreases on taking rest.
Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Trachea appears to be central
Chest moves on respiration and equal on both sides.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.
AP Diameter-30cms
Transverse diameter-34cms
Percussion:on sitting position
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion:Stony dull note heard over left ISA,IAA
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over left ISA,IAA.
No added sounds like ,wheeze.
Decreased vocal resonance over left ISA,IAA
Crepitations heard over left ISA,IAA
CVS EXAMINATION:
JVP- Not raised,normal wave pattern.
-on inspection:
shape of chest wall elliptical, no visible pulsations, no engorged veins present.
Apical impulse is not visible
Palpation:
apex beat over left 5th intercostal space medial to midclavicular line. No parasternal heaves
No precordial thrill
No dilated veins
Auscultation:s1 and s2 heard no murmurs heard.
PER ABDOMEN EXAMINATION:
Inspection:
Shape of the abdomen:Rounded
Flanks:Free
Umbilicus:center,oval shape
Skin-normal,no sinuses,scars,striae
No dilated viens
Abdominal wall moves with respiration
No hernial orifices
Palpation:
No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation.
Liver:Not palpable,Non tender,no hepatomegaly
Spleen:Not palpable,non tender,no splenomegaly
Kidney:Non tender and not palpable
No other palpable swellings
Percussion:
On abdomen percussion tympanic note is heard
Liver span:12cms in mid clavicular line
Spleen:No dullness is heard
CNS EXAMINATION:
Higher mental functions:
Patient is conscious,coherent,cooperative,
Speech and language is normal
CRANIAL NERVES:Intact
Olfactory nerve
Optic nerve
Occulomotor nerve
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Spinal accessory
Hypoglossal
Motor system:
Right Left
Bulk UL n n
LL n n
Tone UL n n
LL n n
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Superficial reflexes: present
Corneal
Conjunctival
Abdominal
Plantar reflexes
Deep reflexes:Present
Right Left
Biceps ++ ++
Triceps ++ ++
Knee ++ ++
Ankle ++ ++
Co ordination present
Gait normal
No involuntary movements
Sensory system:
Pain, temperature, pressure, vibration perceived
Romberg's test:absent
Graphaesthesia:normal
Cerebellar signs:
No nystagmus,Finger nose test positive,Heel knee test positive
No signs of meningeal irritation.
PROVISIONAL DIAGNOSIS:
LEFT SIDED PLEURAL EFFUSION.
Investigations:
On 08/03/2023,
Her ESR levels were 170mm in first hour
Pleural fluid cell count:
Total WBC count-2400 per mm3
Polymorphs-80%
Culture sensitivity-negative
LFT:
Serum total bilirubin:1.1mgl
Serum direct bilirubin:0.4mg/dl
C-reactive protein:61.7mg/l
Chest x ray showing:
Inj.PAN-40gm,iv,od. Tab.PARACETAMOL-650m,po,tid
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od
Inj.LEVOFLOXACIN-750 mg,iv,od.
DIAGNOSIS:
LEFT LOWER LOBE PNEUMONIA WITH SYNPNEUMONIC EFFUSION.
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