Thursday 9 June 2022

1701006077- short case final mbbs practical

 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.


A 69 year old male farmer , resident of nalgonda presented to Casualty with complaints of 
• SHORTNESS OF BREATH SINCE 20 DAYS 
•COUGH SINCE 20 DAYS
• FEVER SINCE 4 DAYS



● Personal history 
Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate 
Addictions :- He smokes 4 beedis per day for the past 50 years. Consumes 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
           

Blood pressure :-  120/80 mmHg taken from Left arm  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 infraclavicular area


Percussion 

 supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas are percussed.

Dull note was noted in Right infraclavicular and suprascapular areas  
All other areas were resonant

Auscultation

 Diminished breath sounds in Right infraclavicular area and Right Suprascapular area 
Fine crepitations heard in Right mammary and infra axillary area
Vocal resonance - increased in right suprascapular and infraclavicular area

● 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 are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation
Gait : normal
No signs of cerebellar dysfunction


● PROVISIONAL DIAGNOSIS

Right Lung 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 lakhs

3. COMPLETE URINE EXAMINATION:
Normal

4. ABG: 
     pH:-7.44
     pCO2 :-34.3
     pO2:-68.3
     HCO3:-23.4 

5. LIVER FUNCTION TESTS
   TOTAL BILIRUBIN :-0.45
   DIRECT BILIRUBIN:-0.17
   AST :-28
   ALT:-27
   ALP:-202
   ALBUMIN:-2.73
  
6.ECG

7. XRAY CHEST 








● Treatment :-

1. Inj.Augmentin
2. Nebulisation with Duolin (BD)and budecort (TID)
3.Syp.Cremaffin 10 mL 
4.Monitoring of vitals
5. Spo2 monitoring 
6.Inj- PAN -40  mg OD
7.ASCORIL - LS( 2 table spoons)

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