This 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.
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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.
●CHIEF COMPLAINTS:-
A 35 year old female,resident of miryalguda,worker in steel shop,came with chief complaints of
•Fever since 12 days
•Shortness of breath since 10 days
•Cough since 8 days
●HISTORY OF PRESENTING ILLNESS:-
She was apparently asymptomatic 12 days back,and then she developed fever which was insidious in onset,continuous,high grade and not associated with chills and rigors,for which she went near local RMP and took some medications and temperature decreased.
And then she developed breathlessness 10 days back,which was insidious in onset,gradually progressive,SOB is of grade 1 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, and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.
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 1 SOB.
She is not a known case of Diabetes mellitus,Hypertension,Tuberculosis,Epilepsy.
●PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal
Sleep: Adequate
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,generalised edema.
Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.
SYSTEMIC EXAMINATION:
●RESPIRATORY SYSTEM:
-Upper respiratory tract: No polyps and DNS
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.
No accessory respiratory muscles are used in respiration.
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
Circumference-inspiratory-113cms, expiratory-110cms
Percussion:on sitting position
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion:Stony dull note heard over left ISA(infrascapular),IAA (infraaxillary)
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over left ISA,IAA.
No added sounds like Crackles,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
Umbilicus:center
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
Auscultation:
Bowel sounds heard
●CNS EXAMINATION:
Higher mental functions:
Patient is conscious,coherent,cooperative,
Speech and language is normal
CRANIAL NERVES:Intact
Olfactory nerve -Intact
Optic nerve -Intact
Occulomotor nerve-Intact
Trochlear-intact
Trigeminal -intact
Abducens -intact
Facial -intact
Vestibulocochlear -intact
Glossopharyngeal -intact
Vagus -Intact
Spinal accessory -intact
Hypoglossal- intact
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 ++ ++
Supinator ++ ++
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:-
-COMPLETE BLOOD PICTURE
Hemoglobin-11.5gm/dl*
Total count-10,000cells/cumm
Neutrophils-70%
Lymphocytes-20%
Eosinophils-02%
Monocytes-08%
Basophils-00%
Platelet count-4.24
Interference:Normocytic normochromic smear
SERUM ELECTROLYTES:-
Sodium-136mEq/l (135-145)
Potassium-4.3mEq/l (3.5-5.1)
Chloride-103mEq/l (95-107)
Calcium ionized-0.94mmol/l
LIVER FUNCTION TEST:-
Total bilirubin-0.73 mg/dl(0-1)
Direct bilirubin-0.19mg/dl(0.0-0.2)
SGOT(AST)-32 IU/L(0-31)
SGPT(ALT)-31 IU/L (0-34)
ALP-147 (42-98)
Total proteins-7.8gm/dl
Albumin-3.42gm/dl(6.4-8.3)
A/G ratio-0.78
SERUM URIC ACID:3mg%(2.6-6)
Blood urea-24mg/dl(12-42)
Serum creatinine-0.7(0.6-1.1)
CHEST XRAY:
Chest x ray showing:
Dense uniform opacity in lower lobe and obliteration of costo- phrenic angle indicating left sided pleural effusion.
USG::
Left mild loculated pleural effusion and consolidatory changes noted in left basal segment.
TREATMENT:
Inj.CEFTRIAXONE-1gm,IV,BD
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Inj.LEVOFLOXACIN-750 mg,iv,od.
FINAL DIAGNOSIS:
LEFT LOWER LOBE PNEUMONIA WITH SYNPNEUMONIC EFFUSION.
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