FINAL PRACTICAL EXAMINATION - SHORT 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-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. 

G.Sahithi Reddy

Hall ticket no - 1701006043

 A 71 year old male patient came to opd with
 
 CHIEF COMPLAINTS OF

 Breathlessness and
 cough since 20 days

HISTORY OF PRESENTING ILLNESS

Patient is apparently asymptomatic 20 days back then he developed cough and shortness of breath.

COUGH 
cough is associated with sputum 
color of sputum - whitish( Mucoid) 
Blood tinged sputum ( 2 to 3 episodes)
not associated with odour

DYSPNEA 
insidious in onset
grade III dyspnea 
breathlessness after walking for some distance.(100 yards) 

Associated with right sided chest pain 
which is of dragging type. 

PAST HISTORY

No history of similar complaints in the past 
no history of covid 19 in the past 
No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid abnormalities

PERSONAL HISTORY

Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate 
Addictions :- smokes 3-4 beedis per day since 50 years. Drinks alcohol occasionally.
He used to work as a construction worker ,later he worked as a security gaurd , recently he worked as a farmer but stopped working 5 days before admitting in Hospital 

FAMILY HISTORY

No history of similar complaints in family 

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative 
Thin built and moderately nourished
Weight 37 kgs 

Pallor :- Present 
Icterus :- Absent 
Cyanosis :- Absent 
clubbing :- present (Grade II - Parrot beak appearance )
Lymphadenopathy :- 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

The patient was examined in a well lit room with adequate exposure after taking informed consent

INSPECTION

Upper respiratory tract - Normal
Shape of chest - elliptical & Bilaterally symmetrical 
Trachea - deviated to right side 
Movements - reduced on right side 
no crowding of ribs
no scars and sunuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscles
PALPATION 

No local rise of temperature
No tenderness
All the inspectory findings are confirmed 
Apical Impulse :- 5th intercostal space 2 cm medial to mid clavicular line
Trachea is deviated towards right side (3 finger test ) 
chest expansion 1cm ( Inspiration circumference - expiration circumference) 
Chest diameters 
        Transverse :- 27 cm
        Anteroposterior :-20 cm 
Movements of chest with respiration are reduced on right side 
chest expansion 1cm 
 vocal fremitus - increased on right side
                                    Right                          left
• Supra clavicular   normal              normal
• Clavicular            Increased           normal
• Infra clavicular   Increased            normal
• Mammary           Increased            normal        • Axillary                Increased            normal
• infra axillary       Increased             normal     
• Supra scapular. Increased             normal
• infra scapular    Normal                 normal

PERCUSSION 

 supraclavicular, infraclavicular, mammary, axillary, infra axillary, suprascapular, infrascapular areas are percussed

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

AUSCULTATION
Normal vesicular breath sounds are heard 
decreased breath sounds in Right infraclavicular area and Right Suprascapular area 
No added sounds 

CVS EXAMINATION

Inspection- 
The chest wall is bilaterally symmetrical

Palpation-
Apical impulse is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
 • No parasternal heave 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 
NO HEPATOSPLENOMEGALY


CENTRAL NERVOUS SYSTEM
Higher mental functions are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation

INVESTIGATIONS
PROVISIONAL DIAGNOSIS : 
Right 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 

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 


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 

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 

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 
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 ) 

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 ) 

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