Hall ticket no :16010016057 , 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-centered online learning portfolio and your valuable inputs on the 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. 

CASE:
A 14 year old male  resident of nalgonda , student by occupation,came to opd three days back  with Chief complaints of 
Cough since  8 days 
and shortness of breath since 8 days 
Fever since 8 days

History of present illness :
Patient was apparently asymptomatic
8 days ago
And then he developed fever - insidious onset ,Low grade continuous  a/s with chills and rigors relieved on medication

H/o SOB Since 8 days insidious onset
Progressive from MMRC 1 to 2nd 
Increased on exertion and cough 
Relieved on sitting position,no diurrnal , positional variation 
(No orthopnea and PND)


H/o of dry Cough - since 8 days , insidious onset,non progressive ,no aggravating and relieving factors,no positional variation

Loss of appetite 

No complains of chest pain 
Burning micturition
Loss of weight
No hlo of tb




PAST HISTORY:H/o of similar complaints since5-6 years ( on regular inhaler usage )(asthalin,bordecort) 

no history of TB ,diabetes mellitus , epilepsy, hypertension

PERSONAL HISTORY:
Appetite:decreased appetite 
Diet: mixed 
B and b - regular
Sleep - adequate 
No addictions

FAMILY HISTORY:no history of similar complaints in family



GENERAL EXAMINATION:
Patient is consious, coherent,cooperative,oreinted to time ,place , person comfortably lying on bed 
Moderately built and nourished
 Pallor absent
No signs of 
Cyanosis 
Clubbing
Koilonychia 
Generalized lymphadenopathy


VITALS:pulse : 90 beats per minute

Blood pressure:110/70 mmhg on supine position


Respiratory system-18 cycles per min



Temperature: afebrile



Spo2-95%


LOCAL EXAMINATION OF respiratory system

Inspection:
Shape of chest - elliptical , bilateral symmetrical
No deformity

Trachea position:central , expansion of chest decreased on left side 

Apical impulse couldn't be seen
No use of accessory muscles of respiration
No Supra or infra clavicular hollowness or fullness
No drooping of shoulder
No .crowding of ribs 
No wasting of muscles 

No scars ,sinuses,dialted veins in thorax region 

Spinaspaculular distanced is increased on left side


PALPATION:No local rise in temperature and tenderness
All inspectory findings confirmed by palpation
No local rise of. Temperature
Trachea : central
Chest movements decreased on left side
Apex beat:left 5th intercoastalspace 1cm to the medial to MCL
TVF -decreased on left infra scapular ,IAA,AA ,


Percussion:
Direct: resonant 
Indirect -dull on left infra SA and inter SA 
AA;IAA 


Auscultation:

Bilateral air entry : positive 
 Decreased breath sounds - ISA,IAA,interscapular area
Added sounds: absent 

CVS system :
S1
S2 present 
No murmurs 


Per abdomen : soft,non tender,no organomegaly

CNS EXAMINATION: intact 


INVESTIGATIONS: 
Haemogram :slight decrease in haemoglobin

complete urine examination - normal 
Chest X ray:

Thoracocentesis- 
Pleural  fluid: sugar and protein normal

Serum electrolytes: chloride is increased
Liver function test:t
Total bilirubin and direct bilirubin increased 

SGPT (ALT) - normal 
ALP- normal 
SGOT(AST) -normal 

ECG
ultrasound:
serology 
Serum protein is decreased
Serum LDH - decreased
Analysis:
Treatment: conservative treatment 
1:

Cefixime 200mg bd
Azithromycin 500 mg od

Tablet pantoprazole 
40 mg od

(Nebulizer with asthalin 6th hourly)
Budecort 8th hourly 

Montac - OD

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