FINAL PRACTICAL EXAMINATION: LONG CASE PRESENTATION

Admission no. : 1701006109

• This is 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 a series of inputs from an 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 in the comment box  is welcome

A case of 19 y/o Male with Dyspnea and Fever

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.

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

CHIEF COMPLAINTS: 

A 19 year old male student came to the department with the chief complaints of shortness of 

• Breath since 10 days
• Fever since 10 days
• Cough since 3 days.

HISTORY OF PRESENTING ILLNESS : 

• Patient was apparently asymptomatic 15 days back , then he developed shortness of breath on mild exercise like walking up the stairs ( grade 3 ) for which he went to Nalgonda government hospital after which it subsided on treatment. 
• 10 days ago he had another episode of shortness of breath (grade 1)  which was associated with fever. The patient was referred to our hospital for further treatment.
• The fever was sudden in onset , intermittent , low grade , not associated with chills and rigors and no evening rise of temperature.
• The patient had cough since 3 days which was non productive which was relieved on medication
• There was no history of palpitations , orthopnea, paroxysmal nocturnal dyspnoea.
• There is a history of loss of weight of about 5 kg in 2months
• No complaints of chest pain , hemoptysis.

PAST HISTORY : 

• No history of similar complains in the past 
• No history of TB , diabetes , hypertension , bronchial asthma and epilepsy.

FAMILY HISTORY :

• No history of similar complaints in the family 

PERSONAL HISTORY : 

• Appetite : Normal 
• Diet : Mixed
• Sleep : Adequate
• Bowel and bladder movements : Normal 
• No addictions and no drug allergies 
• Occupation : Student 

DAILY ROUTINE OF THE PATIENT : 

The patient is student by occupation. He lives in a hostel in Hyderabad and is currently pursuing his B.Tech degree.

A usual day in his life: 

• 7.00am : wakes up and takes a walk after freshening up 
• 8.30 am : Breakfast
• 9.00 am - 4.00 pm : College hours. Has lunch at 1.00pm
• 4.30 - 6.00 pm : Takes a nap 
• 6.30 - 8.30 pm : College work 
• 8.30pm : Dinner 
• 9.00 - 10.30 pm : Leisure time 
• 11.00 pm : Goes to sleep 

GENERAL EXAMINATION : 

• Patient is conscious , coherent and cooperative, moderately built and nourished and well oriented to time , place and person. 
• Pallor - Absent
• Icterus - Absent 
• Clubbing - Absent
• Cyanosis - Absent
• Lymphadenopathy - Absent
• Edema - Absent 

VITALS : 

• Temperature : Febrile
• Pulse : 98 beats per minute
• Respiratory rate : 16 cycles per minute
• Blood pressure : 120/85 mm of Hg

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM : 

INSPECTION :

• Shape of the chest : elliptical
• Symmetry : bilaterally symmetrical 
• Trachea : Central in position 
• Expansion of the chest : Decreased on left side
• Accessory muscles use for respiration : Not present 
• Type of respiration : Abdomino-thoracic
• No dilated veins, pulsations, scars, sinuses.
• No drooping of shoulders 
• Right sided supraclavicular , infraclavicular hollow present
• No crowding of ribs 
• Spino-scapular distance equal on both sides 

PALPATION :

• All inspectory findings are confirmed 
• No local rise of temperature 
• No tenderness 
• Trachea deviated to right side 
• Anteroposterior diameter- 21cm
• Transverse diameter-30cm 
• Ratio: AP/T- 0.7
• Chest expansion: 2.5 cm
• Chest movements decreased on left side 
• Tactile vocal Fremitus decreased on left infra scapular area 
• Vocal resonance decreased on left infra scapular area 

Video of examination of chest expansion :

PERCUSSION : 

• Left- 
• Direct : dull 
• Indirect : dull 
• Liver dullness for right 5th intercostal space 
• Cardiac dullness within normal limits 

AUSCULTATION : 

• Bilateral air entry present 
• Normal vesicular breath sounds heard 
• Decreased intensity of breath sounds in left InfraMammary Area , InfraAxillary Area .
• Absent breath sounds in Infra scapular area. 

CARDIOVASCULAR SYSTEM : 

 INSPECTION:

• Chest wall - bilaterally symmetrical
• No dilated veins, scars, sinuses
• Apical impulse and pulsations cannot be appreciated

PALPATION:

• Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
• No parasternal heave, thrills felt.

PERCUSSION:

• Right and left heart borders percussed.

AUSCULTATION:

• S1 and S2 heard , no added thrills and murmurs heard.

PER ABDOMEN : 

INSPECTION:

• Shape – scaphoid
• Flanks – free
• Umbilicus –central in position , inverted.
• All quadrants of abdomen are moving equally with respiration.
• No dilated veins, hernial orifices, sinuses
• No visible pulsations.

PALPATION:

• No local rise of temperature and tenderness
• All inspectorial findings are confirmed.
• No guarding, rigidity
• Deep palpation- no Hepatomegaly or splenomegaly.

PERCUSSION:

• There is no fluid thrill , shifting dullness.
• Percussion over abdomen- tympanic note heard.

AUSCULTATION:

• Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM : 

• No focal neurological deficits
• Sensory and motor systems intact 
• Normal power , tone and reflexes 

INVESTIGATIONS : 

COMPLETE BLOOD PICTURE 

• Hemoglobin 12.1 gm/dl
• Total Count 5.700 cells/cumm
• Neutrophils 53%
• Lymphocytes 35%
• Eosinophils 02 %
• Monocytes 10%
• Basophils 0%
• Platelet Count 3.88 lakhs/cu.mm
• Smear : Normocytic normochromic 

LIVER FUNCTION TESTS : 

• Total Bilirubin 0.83 mg/dl
• Direct Bilirubin 0.20 mg/dl
• SGOT(AST) 17 IU/L
• SGPT(ALT) 22 IU/L
• Alkaline Phosphate 215 IU/L
• Total Proteins 6.7 gm/dl
• Albumin 3.59 gm/dl
• A/g Ratio 1.15

RENAL FUNCTION TESTS : 

• Urea 17 mg/dl
• Creatinine 0.8 mg/dl
• Uric Acid 5.6 mg/dl
• Calcium 10.2 mg/dl
• Phosphorous 3.3 mg/dl
• Sodium 138 mEq/L
• Potassium 3.8 mEq/L
• Chloride 99 mEq/L

COMPLETE URINE EXAMINATIONS :

RANDOM BLOOD SUGAR : 

• RBS: 112 mg/dl 

XRAY : 

On admission : 01/06/22

 06/06/22

ULTRASOUND : 

LEFT MODERATE TO GROSS PLEURAL EFFUSION WITH COLLAPSE OF UNDERLYING LUNG SEGMENTS

PLEURAL FLUID ANALYSIS : 

• SUGAR 93
• PROTEINS-51 
• Total count - 1250
• Differential count - 90 % neutrophils , 10% leukocytes. 

ECG REPORT : 

PROVISIONAL DIAGNOSIS : 

Left sided pleural effusion 

TREATMENT : 

Medical Treatment:

2/6/22 : 

1.02 INHALATION WITH NASAL PRONGS ELITIM

2.INJ AUGMENTIN 1.2GM IV TID

3.INJ PAN 40 MG OD BBF

4.T DOLO 650MG PO SOS

5. SYRUP GRILLINCTUS DX 2 TSP TID 

3/6/22 : 

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

4/6/22 :

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

5.NEBULIZATION WITH MUCOMIST 

5/6/22 : 

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

5.NEBULIZATION WITH MUCOMIST 

6/2/22 : 

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF. 

3.SYRUP GRILLINCTUS DX 2 TSP TID 

4. Started with ATT (Antitubercular therapy) regimen

Interventional procedures : 

1/06/22 : Diagnostic tap was performed 20 mL was aspirated

2/06/22 : 250 mL straw coloured fluid was aspirated

3/06/22 : 1000 mL straw coloured fluid was aspirated

5/06/22 :20 ml of straw coloured fluid was aspirated 

Procedures were uneventful without the occurrence of any complications 

Advice On Discharge : 

1. ATT 4 TABLETS A DAY BEFORE BREAKFAST

2. TAB CEFIXIME 200MG BD FOR 5 DAYS

3. TAB PAN 40 MG PO OD BEFORE BREAKFAST

4. HIGH PROTEIN DIET

5. 2 EGG WHITES PER DAYS