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 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.

HALLTICKET NO:1701006065

Case Details: 


A 69 year old male, agricultural labourer by occupation hailing from panthangi has come to the hospital with the following complaints

1. SHORTNESS OF BREATH SINCE 20 DAYS 

2. COUGH SINCE 20 DAYS

3. FEVER SINCE 4 DAYS


HISTORY OF PRESENT ILLNESS

The patient was apparently alright 20 days ago, then he developed Shortness of breath which was insidious in onset, MMRC grade 2-3 aggravated on Exertion and exposure to cold ,releived on taking rest. There is no history of breathlessness on lying down or Sleep disturbance due to SOB.


He also complains of Cough with expectoration- sputum is mucoid, non blood stained, non foul smelling. No aggrevating factors, releived on rest.

He also complains of fever since 4 days which was insidious in onset, continuous in nature. No Chills and rigors. Fever was releived on taking medication.


Patient gives a history of loss of appetite and loss of weight and also dragging sensation in the right side of chest


The patient denies history of Nasal obstruction,nasal discharge, sore throat, hoarseness of voice , noisy breathing and chest pain 


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 :- He smokes 4 beedis per day since 50 years. He takes alcohol occasionally. 

Family history 

No history of similar complaints in family 


GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative 

Thin built and moderately nourished

Pallor :- Present 

Icterus :- Absent 

Cyanosis :- Absent 

Lymphadenopathy :-Absent

Pedal Edema :-Absent 


Vital signs

Temperature :- He is afebrile 

Respiratory Rate :-22 cycles per minute 

Pulse :- 

         Rate :-80 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 EXAMINATION


Upper respiratory tract :- Normal


Examination of Chest :

Inspection:

The chest appears to be normal and bilaterally symmetrical

Trachea appears to be central in position 

Apical impulse is seen in fifth intercostal space 

No bony abnormalities of chest 

Movements of chest with respiration appear to be reduced on the right side 

No evidence of usage of accessory muscles for respiration

No scars and sinuses seen 

No dilated veins are seen on the chest wall 


Palpation:



No local rise of temperature

No tenderness

All the inspectory findings are confirmed 

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

Chest diameters 

        Transverse :- 27 cm

        Anteroposterior :-20 cm 

Movements of chest with respiration are reduced on right side 

Apical Impulse :- 5th intercostal space 1 cm medial to mid clavicular line

Vocal fremitus -increased in Right suprascapular and right infraclavicular area 


Percussion :

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillarysuprascapular, infrascapular areas.

Dull note was noted in Right infraclavicular and suprascapular areas

All other areas were resonant.

Auscultation:

Normal vesicular breath sounds heard

Diminished breath sounds in Right infraclavicular area and Right Suprascapular area

Fine crepitations heard in Right mammary and infra axillary are

Vocal resonance increased in right Infraclavicular and Right suprascapular areas.


CARDIOVASCULAR SYSTEM: 


Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 


Palpation-

Apical impulse is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

No parasternal heave felt

No thrill felt


Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

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

PER ABDOMINAL EXAMINATION :- 

Soft and non tender 

NO HEPATOSPLENOMEGALY


CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is conscious ,coherent and cooperative 

                Right handed individual

                Memory - immediate , short term and long term memory are assessed and are normal 

                Language and speech are normal

                Cranial nerves :- intact 

Sensory system :- 

Sensation                   right                    left

 Touch                        felt                       felt

Pressure                     felt                       felt 

Pain 

-superficial                felt                        felt

-deep                         felt                       felt

Proprioception          

-joint position         ✔                     ✓

-joint movement    ✔                      ✓   

Temperature         felt                      felt

Vibration                felt                      felt

Stereognosis           ✔                       ✓


Motor system


                              Right.                  Left

BULK 


Upper limbs.           N.                       N


Lower limbs             N.                      N



TONE


 Upper limbs.             N.                      N


 Lower limbs.             N.                      N



POWER


 Upper limbs.             5/5.                     5/5


 Lower limbs             5/5.                      5/5

Gait :- Normal

Superficial and deep reflexes are elicited

No signs suggestive of cerebellar dysfunction


PROVISIONAL DIAGNOSIS

Right Upper lobe fibrosis 


Investigations 

1.Sputum examination 

Negative for acid fast bacilli 


2. COMPLETE BLOOD PICTURE 

    Hb :- 11.7

    TLC :- 15400

    NEUTROPHILS:-82

    EOSINOPHILS :-01

    BASOPHILS :-00

    LYMPHOCYTES:-10

    MONOCYTES- 7

    PCV:-34.7

    RBC count :- 3.83 millions

    PLATELETS:-2.83 lakhs3. 

COMPLETE URINE EXAMINATION:Normal


4. ABG

     pH:-7.4

     pCO2 :-34.

     pO2:-68.

     HCO3:-23.4


5. LIVER FUNCTION TES

   TOTAL BILIRUBIN :-0.4

   DIRECT BILIRUBIN:-0.1

   AST :-2

   ALT:-2

   ALP:-20

   ALBUMIN:-2.7327875TS 334BG 


 

6.ECG







7. XRAY Chest









8. 2D ECHO :- 

No regional wall motion abnormality

Ejection fraction :-6

Mild diastolic dysfunction present




Treatment

1. Inj.Augmenti

2. Nebulisation with Duolin (BD)and budecort (TID

3.Syp.Chromaffin 10 mL

4.Monitoring of vital

5. Spo2 monitoring

6.Inj- PAN -40  mg O

7.ASCORIL - CS ( 2 table spoon

sD s )nent  7 

















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