LONG CASE:- Practical Final Examination (70 YEAR OLD MALE WITH SHORTNESS OF BREATH SINCE ONE MONTH)

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I have 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, and investigations, and come up with a  diagnosis and treatment plan.

Hallticket Number:-1701006148

CASE PRESENTATION:-

A 70 year old male came with the 

*Chief Complaints of:-

-Shortness of breath since 20 days.

-Cough since 20 days.

*History of present illness:-

Pateint was apparently asymptomatic 10 years back then he developed 

•Shortness of breath and cough- which has been treated in nearby hospital with intercostal tube drainage and he said he used medications for tb for 4 months.

•Now, patient complains of shortness of breath-insidious in onset, gradually progressive- Grade 2 not associated with wheezing, No postural variation, No diurnal variation, No history of orthopnea and PND, Relieved on Rest.

 

•Cough is present on and off with sputum-Mucoid in consistency,Non foul smelling,Not blood stained, No diurnal variation, Relieved on medication.

•Loss of weight present.

•No history of chest pain, chest tightness.

*Past History:-

•Not a known case of Diabetes Mellitus, Hypertension, Asthma and Epliepsy.

*Family History:- Not significant

*Personal History:-

•Takes mixed diet

•Apetite:-Decreased

•Sleep is Adequate

•Bowel Habits:-Normal

•Bladder habits:-Normal

•No known allergies 

•Addictions:-Alcohlic since 50 years and Chronic smoker-smoked for 40 years-1chutta per day, stopped 10 years back.

*General Physical Examination:-

•Patient is conscious,coherent and cooperative and well oriented to time, place and person.

•He is moderately built.

•Pallor:- Absent

•Icterus:-Absent

•Cyanosis:- Absent

•Clubbing :- Absent

•Lymphadenopathy:- Absent

•Edema:-Absent

*Vitals:-

••Patient is afebrile

••Pulse rate:-82 bpm

••Blood pressure:-130/80 mm of Hg

••Respirtaory rate:-28 cpm

••SpO2:-96% on Room temperature

••GRBS:-113mg%

*Clinical Images:-

*Systemic Examination:-

••Respiratory System:-

••Inspection:-

*Upper Respiratory Tract:- 

•Nose:-No DNS, polyps,turbinate hypertrophy

•Oral cavity:-Poor oral hygiene

•Posterior pharyngeal wall:-Normal

*Lower Respiratory Tract:-

•Shape of the chest:-bilaterally symmetrical,Elliptical

•Trachea:- Appear to be central

•Apical Impulse is not appreciated.

•Chest expansion:- Decreased movements on right side.

•No usage of Accessory muscles of respiration

•No dilated veins,scars, sinuses.

•No kyphosis/Scoliosis

••Palpation:-

•All Inspectory findings are confirmed. 

•No local rise of temperature. 

•Trachea:- midline in position

•Apical impulse is felt at the left 5th intercoastal space.

•Tactile Vocal fremitus:- decreased on right side infrascpular and infraaxillary area

•AP diameter:-21cms 

•Transverse diameter:-25cms

•Chest circumference:- inspiration:- 74cm

                                         expiration:- 75cm

•Right hemithorax:-39 cm

•Left hemithorax:-39 cm

••Percussion:-

•Dullness noted in right sided Infrascapular area and infraaxillary area

•Done on both sides in the following areas:-

-Supraclavicular-resonant on both sides

-Infraclavicular-resonant on both sides

-Mammary-resonant on both sides

-Axillary-resonant on both sides

-Infraaxillary-Stony Dull note on Right side, Resonant on left side

-Suprascapular-resonant on both sides

-Infrascapular-Stony Dull note on Right side , Resonant on left side

-Upper/mid/lower interscapular-Resonant on both sides

••Auscultation:- 

•Done on both sides of the chest.

•Bilateral Air Entry:- Present

•Decreased Air Entry on Right Infrascapular area, Infraaxillary area.

•Vocal Resonance:- Decreased on Right Infraaxillary area

•No added sounds.

••Abdomen Examination:-

••Inspection:-

•Shape – scaphoid

•Flanks – free

•Umbilicus –central in position , inverted.

•All quadrants of abdomen are moving equally with respiration.

•No dilated veins, hernial orifices, sinuses

•No visible pulsations.

••Palpation:-

•No local rise of temperature and tenderness

•All inspectory findings are confirmed.

•No guarding, rigidity

•Deep palpation- no organomegaly. 

••Percussion:-

•There is no fluid thrill and shifting dullness.

••Auscultation:-

•Bowel sounds are heard.

••Cardiovascular system Examination:-

••Inspection:-

•Chest wall - bilaterally symmetrical

•No dilated veins, scars, sinuses

•Apical impulse and pulsations cannot be appreciated

••Palpation:-

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

•No parasternal heave, thrills felt

••Auscultation:-

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

••Central nervous system:-

•Higher Mental Functions:-

Patient is Conscious, well oriented to time, place and person.

•All cranial nerves:-intact

•Motor system:-Intact

•Superficial reflexes and deep reflexes:-present and normal

•Gait:- normal

•No involuntary movements

•Sensory system:-All sensation(pain, touch, temperature, position, vibration sense)are well appreciated.

Provisional Diagnosis:- Right sided Pleural Effusion secondary to Tuberculosis. 

Investigations:-

*Complete Blood Picture:-

*Complete Urine Examination:-

*Blood Urea:-

*Serum Creatinine:-

*Serum Uric acid :-

*Liver Function Tests:-

*Serum Electrolytes:-

*HbsAg-Rapid:-

*HIV Rapid:-

*Ultrasound:-

1.Right moderate Pleural effusion

2.Mild bilateral chest consolidatory changes.

*Pleural fuld Analysis:- Report pending

*Chest X-Ray:-

Treatment:-

•Inj.AUGMENTIN:- 2gm IV/TID

•Oxygen with nasal prongs to maintain SpO2 >94%

•Inj.PAN 40 mg IV/OD

•Tab.MUCINAC Ab-TID

•Tab.PCM 650 mg(SOS) 

•Syrup.ASCORYL-C5 2tbsp-TID

•Tab.OROFER-XT-OD

•Monitor vitals