FINAL EXAM LONG CASE

 This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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 a diagnosis and treatment plan.

Hall ticket no. 1701006048


CHIEF COMPLAINTS:

71 year old male came to the opd with chief complaint of

• Shortness of breath since 20 days.

• Cough since 20 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back then he developed 

•Shortness of breath since 20 days, which is insidious in onset and gradually progressive.  Grade 3 according to MRC grading.
Aggrevated on walking, relieved on taking rest.

• Cough since 20 days, no diurnal variation, no postural variation,associated with sputum, which is mucoid, minimal amount, not foul smelling, not blood stained but with heavy bouts of cough, blood stained sputum is noticed.

✓ associated with right sided chest pain, which is intermittent and dragging type pain.

✓ No H/o Fever, Hemoptysis.

PAST HISTORY:

No History of similar complaints in the past.

No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid problems.

PERSONAL HISTORY 
Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate 
Addictions :- smokes 3-4 beedis per day since 50 years. Drinks alcohol occasionally.
He used to work as a construction worker for 30 years ,later he worked as a security gaurd , recently he worked as a farmer but stopped working 5 days before admitting in Hospital 

FAMILY HISTORY 
No history of similar complaints in family


GENERAL PHYSICAL EXAMINATION

Patient is conscious, coherent and cooperative 
Thin built and moderately nourished. 
Weight :34kgs

Pallor :- Present 
Clubbing: present
Icterus :- Absent 
Cyanosis :- Absent 
Lymphadenopathy :-Absent
Pedal Edema :-Absent 

VITALS:

Temperature :- Afebrile

Respiratory Rate :- 24 cycles per minute.

Pulse :- 

         Rate :-77 beats per minute 
         Rhythm :- Regular 
         Volume :- normal
         Character :- normal
         Condition of vessel wall :- Normal/soft
         No radio radial or Radio femoral delay  

Blood pressure :-  120/80 mmHg taken from Left arm ,measured in sitting position.

SYSTEMIC EXAMINATION 

The patient was examined in a well lit room after taking a valid informed consent after adequate exposure.

RESPIRATORY SYSTEM:

INSPECTION: 




    



• Shape of chest: Bilateral symmetrical, elliptical.

 • Position of trachea: right side deviated.

• Apical impulse: not visible.

• Respiratory Movements - reduced on right side 

•no crowding of ribs
no scars and sinuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscles.

PALPATION:

No local rise of temperature

 No Tenderness is present.

All the inspectory findings are confirmed 

Trachea is deviated towards right side (by 3 finger test) 






Movements of chest with respiration are reduced on right side 

Apical Impulse :- 5th intercostal space 2 cm medial mid clavicular line.

Chest diameters 

        Transverse :- 27 cm



        Anteroposterior :-20 cm 

Measurement of chest expansion:  1 cm.

Vocal fremitus:                   RIGHT.                   LEFT

Supraclavicular.               INCREASED.     NORMAL

Infraclavicular           INCREASED.  NORMAL

Mammary.                   NORMAL.     NORMAL

Axillary.                      INCREASED.   NORMAL

Infraaxillary.               NORMAL.     NORMAL

Suprascapular.          INCREASED.  NORMAL

Infrascapular.            NORMAL.     NORMAL


PERCUSSION:


Supraclavicular.                   DULL.        RESONANT

Infraclavicular                DULL.   RESONANT

Mammary.              RESONANT   RESONANT

Axillary.                  RESONANT   RESONANT

Infraaxillary.          RESONANT.  RESONANT

Suprascapular.            DULL .      RESONANT

Infrascapular.         RESONANT   RESONANT












AUSCULTATION:

Normal vesicular breath sounds heard 

Diminished breath sounds in Right infraclavicular area and Right Suprascapular area 

No added sounds .


CARDIOVASCULAR SYSTEM:

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse not visible.

Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm medial to  the midclavicular line

No parasternal heave felt

No thrill felt



Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


PER ABDOMINAL EXAMINATION :- 

Soft and no tenderness.

NO HEPATOSPLENOMEGALY

CENTRAL NERVOUS SYSTEM 

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation.






ACID FAST BACILLI- NEGATIVE




PROVISIONAL DIAGNOSIS 

Right upper lobe consolidation


 VITALS:

DAY 1 

BP- 110/80 mm hg

pulse- 88 bpm

respiratory rate -28 cpm

spo2 -96% 


DAY 2 

 BP -120/80 mm hg

pulse -89 bpm

respiratory rate -26 cpm

spo2 -96% 


DAY 3 

BP -120/80 mm hg 

PULSE -94 bpm

RR-14 cpm

SPO2 -92% (on room air )

96%  ( with 2 lits of oxygen)


 DAY 4 

BP -120/80 mm hg 

PULSE -90 bpm

RR-24cpm

SPO2 -96% (on room air )


DAY 5

BP -120/80 mm hg 

PULSE -88 bpm

RR-22cpm

SPO2 -98% (on room air )


DAY 6

BP -120/80 mm hg 

PULSE -92 bpm 

RR-24cpm

SPO2 -91% (on room air )

97% (with 2 lits of oxygen)


TREATMENT:

DAY 1

injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 


 DAY 2 

injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 



DAY 3

  

injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 


DAY 4


injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 

injection optineuron 100ml OD 

Syrup Ascoril 2 tspns TID 


DAY 5 


injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 

syrup cremaffin 10 ml (per oral ) 


DAY 6 

injection Augmentin 1.2 gms IV TID

injection PAN 40mg IV OD (before breakfast)

Tab paracetamol 650 mg BD 

Nebulization with Budecort BD ,DUOLIN TID 

oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute

Tablet AZEE 500 mg OD 

syrup cremaffin 10 ml (per oral )









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