Final practical short case

Final practical short case

Imama Muhmeen

Roll no 163

Hall tcket no. 1701006060

Mbbs 9th sem

9/6/22  

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan 

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

ACKNOWLEDGEMENTS

1)Few of the Images are taken from the following Elog

https://151arushikimari.blogspot.com/2022/06/final-practical-short-case.html

71 year old male with breathlessness

71 yr old male Mason by occupation came to the general medicine OPD on 1st june,2022 with chief complaints of 

    • Cough since 20 days 

    • Shortness of breath since 20 days

    •fever since 4 days

Daily routine-

He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.

History of present illness-

Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1) and dry cough.

=>2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.

=>20 days back breathlessness was progresses to MMRC grade-2 to 3 (stop for breath after 100 yards of walk ) 

.Associated with wheeze

.Aggrevated on cold exposure,exertion

.Relieved on rest

.No orthopnea and PND

=>20 days back,he developped cough with expectoration

.Mucoid in consistency

.Non foul smelling

.Non blood stained

.Aggrevated at night

=>4 days back,he developped fever,which is continuous and low grade 

.Evening rise of temperature is present

.Relieved on medication

.Not associated with chills and rigors

ASSOSCIATED SYMPTOMS 

• Chest pain on right side since 7 days which is of pricking type ,not radiating and not associated with sweating

• Fever since 4 days insidious in onset , relieved by medication

• Patient gave history of loss of weight and loss of appetite

 

  History of past illness-

.No history of similar complaints in the past

.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.

PERSONAL HISTORY

• Appetite : Decreased since 2 months

• Diet : mixed 

• Bowel and bladder : on alternate days 

• sleep : disturbed due to pain 

• Addictions : habit of smoking beedi since 40 yrs and drinks toddy from 22yrs of age, alcoholic on occasions

(~staphed smoking and alchol/ intake since 2 mothns).

FAMILY HISTORY

• No similar complaints in the past or in family members

GENERAL EXAMINATION

 Patient is conscious, coherent ,well oriented to time,place,persons 

thin built and moderately nourished

Pallor : present

Icterus: absent

Cyanosis: absent

Clubbing : present (grade 2)

Lymphedenopathy : absent

Pedal edema : absent

VITAL SIGNS

Temperature :- afebrile 

Respiratory Rate :- 22 cycles per minute (tachypnea)

Pulse:-79 beats per minute 

Blood pressure :- 120/80 mmHg 

taken from Left arm ,measured in sitting position 

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)

GRB 108mg /dl

 

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)

SYSTEMIC EXAMINATION

   

       》》REXPIRATORY SYSTEM  

        INSPECTION

Upper respiratory tract

    Oral cavity -normal 

     Nose - normal

     Pharynx -normal 

Shape of chest - Elliptical and bilaterally symmetrical 

Trachea - deviated to right side 

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 muscle

No spinal deformities

MOVEMENT OF THE CHEST 

Rate : 22 cpm Tachypnoea

Movements decreased on right side 

PULPATION

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 

Apical impulse : shifted to right (2 cms medial to mid clavicular line )

Chest expansion :1 cm 

Chest movements decreased on right side

NO tenderness over the chest wall 

Vocal fermitus : 

   • Increased on right side at infraclavicular and mammary areas 

   • normal on left side 

PERCUSZION

• Dull note on right side at infraclavicular and mammary areas

• Resonant on left side

ASCULTASION

• Normal vesicular breath sounds heard ,

•Diminished breath sounds in infraclavicular area 

•No other added sounds 

      》CARDIOVASCULAR SYSTEM

INSPECTION

•The chest wall is bilaterally symmetrical

PALPTATION

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

 • No parasternal heave felt

AUSCULFATION

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

            》》P/A EXAMINAKION

Soft and no organomegalu

           》》CENTRAL NERVOUSB SYSTEM

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

.Speech- normal

.cranial nerves- normal

.Motor system- normal

.Sensory system- normal

.Reflexes-normal

.Gait- normal

》INVESTIGATIONS

_HEMOGRAM

COMPLETE URINEX AMINATION

 _LFT

2D ECHO

HRCT

ECG

 HbsAg

 

HIV

HepaTiTiS C

AFB CULTURE

    RFT

 Urea-31 mg/ dl

.Creatinine-0.9

.Uric acid-3.1

.calcium- 10

.phospate-3.3

.sodium-128

.chlorine-95

.potassium-4.2

ABG-

.pH-7.44

.pCO2-34.3

.pO2 -68.3

.HCO3-23.4

.Needle thoracocentasis was done on 5 th June,2022.

.Under ultrasound guidance

.Fluid aspirated was 20 ml 

.Straw coloured

PROVISIONAL DIAGNOSIZ

 RIGHT Lung UPPER LOBE CONSOLIDATION 

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 

 >2/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 102 bpm

RR-26 com

SpO2-90% on RA

           98% on 2 lit oxygen

Respiratory system examination-

Crepitations- right midaxillary area

Decreased breath sounds on right side upper lobe

 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 

=>03/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 89 bpm

RR-26 com

SpO2-96% on RA

  

Respiratory system examination-

Crepitations- right midaxillary area

Decreased breath sounds on right side upper lobe

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 

04/06/2022-

O/E - patient is conscious, coherent, cooperative.

Temperature-98.7°F

BP-120/80 mmHg

PR- 94 bpm

RR-14 com

SpO2-92% on RA

           96% on 2 litres oxygen

Respiratory system examination-

Bilateral air entry- present

No added sounds

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 

05/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 90 bpm

RR-24 com

SpO2-96% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds 

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 , mucomol 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 ) 

06/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 88 bpm

RR-22com

SpO2-98% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds 

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 )

07/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 88 bpm

RR-22com

SpO2-98% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds