1601006072 Long case

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-centered online learning portfolio and your valuable inputs on the comment 


40 year old male, labourer by occupation, low socioeconomic status from narketpalli came to opd with 

Cheif complaints:
Breathlessness since 1month
Fever since 10 days
Chest pain since 4 days

History of present illness:
Patient was apparently asymptomatic 1 month back, then developed
Breathlessness which was insidious onset which used to be grade 2(MMRC)   and progressed to grade 4 since last 4 days with no postural or diurnal variation associated  with generalised weakness and  followed by 

Low grade fever on and off since 10 days  not associated with chills and rigor, shows no diurnal variation and relieved on medication, and 

Cough since 7 days, associated with moderate amount of purulent sputum mixed with saliva which is whitish in colour with no postural variation and
 
Chestpain on left side on inspiration and coughing since 4days which was non radiating and relieved on lying down.


No complaints of Palpitation, syncopal attack, , haemoptysis, recurrent sore throat, hoarseness, choking episode, joint pains, burning micturition,loose stools,constipation,Nausea,Vomiting.

Past history:
Not a Known case of DM, hypertension, epilepsy, asthma, CVD, TB, thyroid disease

Family history:
 None of patients attenders have similar symptoms, or have asthma, TB, hypertension, or significant co morbidity.

Personal history:
Diet mixed
Appetite decreased
Sleep adequate
Chronic smoker since 14yrs 16-18 beedis/day
Chronic alcoholic since 10yrs and consumes 90ml/day.
Bladder and bowel movements are regular

General examination:
I took the informed consent of the patient before examining.

I  have examined the patient in supine and sitting position.
 Patient is conscious coherent cooperative well oriented to time place and person, has  generalised wasting of muscles and is comfortable on bed.

There is no  pallor, icterus, cyanosis koilonychias, clubbing, lymphadenopathy, pedal edema

 JVP is not elevated, hepatojuglular reflex absent.





 Vitals:
Temperature :Afebrile,98 F

Respiratory rate- 40  cycles per minute

Pulse rate 100 beats/min regular in rhythm character volume 

Blood pressure 90/70 mmHg left arm in sitting position.

Spo2 98% on room air.

Systemic examination

Respiratory system: 
1. Upper airway

Nose normal alae Nasi, septum

Oral cavity teeth pharynx normal no sinus tenderness

2. Examination of chest

INSPECTION

Shape of chest is elliptical

Both the shoulders appear to be at the same level

Trachea appears to be central

Apical impulse is not visible

Skin over chest is normal

Trail sign is absent 

Hollownesss in supraclavicular and infra clavicular fossae  

Movements of respiration:
Tachypnea is present and abdomino thoracic respiration

 PALPATION
No local rise of temperature
No tenderness
Chest is expanding equally on both sides
Tactile vocal fremitus is increased infra axillary infra scapular areas both sides
No palpable thrills crepitation pleural rub



PERCUSSION
Direct percussion on clavicle, sternum and Manubrium is resonant 

Kronig isthmus resonant both sides

Indirect percussion(left) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-6 intercostal spaces are resonant, 5-7 intercostal spaces dull, posterity 9th intercostal space dull
Traube space is dull.

Indirect percussion(right) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-7 intercostal spaces are resonant. posterity 9th intercostal space resonant.

AUSCULTATION

Left side infra clavicular, mammary, supra scapular,  normal vesicular breath sounds, decreased bronchial breath sounds at infra axillary, scapular, infra scapular areas. 

Crepitations at infra scapular area

whispering pectoriloquy is present.(vocal resonance increased)

Right side infra clavicular, mammary, supra scapular, infra axillary, infra scapular areas-vesicular breath sounds

 

Other system examination 

CNS - no facial asymmetry all reflexes are normal 

CVS- S1 S2 heard no added murmurs

ABDOMEN - abdomen is scaphoid with no organomegaly

INVESTIGATIONS:

Chest xray:











Diagnosis:
This could be a case of left lower lobe community acquired pneumonia.

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