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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