MBBS part-2 Final examination case discussion

                           LONG CASE
 
A case of 15yrs old male with complaints of chest pain and breathlessness

ROHITH SOMANI
Reg no:1701006172

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 series of inputs from available global online community of experts with an aim to solve those patients 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 on 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 diagnosis and treatment plan.

Chief complaints::
A 15yr old male patient came with the complaints of:
-Chest pain since 3 months
Fever since 2 months
-Breathlessness since 1 month

History of present illness
Patient was apparently asymptomatic 3 months back then he developed chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning on left side. Pain relieved on sitting.
No history of papitations, orthopnea,PND, pedal edema, vomiting, hemoptysis, trauma. 
Then he developed fever which was intermittent,low grade,more at night,not associated with chills and rigors,and  relieved with medication

Then he developed breathlessness since 1 month grade I(MMRC) Insidious in onset, persistent in nature, aggrevated on lying down and on lying on left side. Relieved on sitting. 
Associated with dry cough 
Not associated with wheeze
No history of , loose stools


Past history

No similar complaints in the past
7yrs back patient had complaints of body pains for which he was managed conservatively
4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital
2 yrs back he developed herpes on left side of face.
No history of DM, HTN, TB, Asthma, epilepsy

Personal history

Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder -constipation since 2to3 yrs
No addictions
No known drug and food allergies

Family history
Not significant

General examination

Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals: 
temperature:99.3F
Pulse rate: 78bpm
Resp rate:18cpm
BP:110/70mmhg
Spo2:98%

Systemic examination

Respiratory system

Inspection:

Shape - elliptical 
 No tracheal deviation 
Chest bilaterally symmetrical
Expansion of chest- normal
Use of accessory muscles - no
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:

No local rise of temperature and tenderness
Inspectory findings confirmed 
 trachea- normal 
Apex beat- 5th intercoastal space,medial to midclavicular line.
Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
Measurements:
Anteroposterior length: 13cm

Transverse length: 28cm

Circumference: 78cm


Percussion:

Dull note heard at the left infraaxillary and infrascapular area
Shifting dullness present on left side

Auscultation:                              

Bilateral air entry present. 
Vesicular breath sounds heard. 
Decreased intensity of breath sounds heard in left infraxillary and infra scapular area
Vocal resonance: decreased in left infraaxillary and infrascapular areas

Abdominal examination

Inspection - 
          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 
          Hernial orifices- free.

Palpation -  

soft, non-tender
no palpable spleen and liver

Percussion -
 tympanic note heard 

Auscultation- normal bowel sounds heard

CARDIOVASCULAR SYSTEM:

Inspection:
Shape of chest- elliptical 
No precordial bulge or pulsations 
JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard No murmurs



CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++
Investigations:
prthrombin time:15sec  normal-10-16sec
HbsAg-Negative
Bleeding time- 2minutes normal -2-7min
Clotting time- 4min30sec  normal-1-9min
APTT-31sec                       normal-24-33sec
CT scan


Bronchoscopy:
USG
provisional diagnosis:
Mild left sided hydropneumothorax

Treatment
-IV normal saline
-high flow O2 inhalation with face mask.
-Tab paracetamol 650mg

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