MEDICINE SHORT CASE

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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. 

CASE PRESENTATION:

34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of 

Chest pain since 7 days. 

cough since 7 days.

Shortness of breath since 4 days. 

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 2 months back then developed shortness of breath and chest pain which worsened since 1 week and he had generalised weakness and loss of weight.

Patient had chronic fever since last 6 months which was intermittent and relieved on medication. 

History of cough associated with sputum which was whitish in colour and purulent but moderate amounts since 7 days.

Shortness of breath gradually progressed from grade 2 to 4 associated with chest tightness and difficulty in breathing no complains of palpitation and syncope attacks.

H/o increased hunger and increased frequency of micturition since 6 months which disturbed his daily activities. 

no H/o burning micturition or loose stools and constipation 

No H/o blurred vision or abdominal pains or cramps or loss of consciousness.

PAST HISTORY:

No similar complaints in the past 

Patient was not a known case of diabetes, hypertension, asthma, epilepsy, cardiovascular disorders, Respiratory disorders.

No previous surgical or treatment history.

FAMILY HISTORY:

No similar complaints in the family.

PERSONAL HISTORY:

Diet: Vegetarian 

Appetite: Decreased 

Sleep:  Disturbed

Bowel and bladder movements: Normal 

Addictions:  Alcohol,180-360 ml/day since 14 years and 16-18 beedis per day.

GENRAL EXAMINATION:

Patient is consious, coherent, cooperative and  moderately built and moderately nourished.

He is comfortably lying on the couch.

There are no signs of pallor, icterus, koilonychia, clubbing, cyanosis, lymphadenopathy, edema.

VITALS:

Temperature: Afebrile 

Blood pressure: 90/60 mmHg

Respiratory rate: 27 cpm

Pulse rate: 100 bpm.

SYSTEMIC EXAMINATION:

Respiratory system:

INSPECTION:

• Shape of the chest: elliptical

• Movements: symmetrical bilaterally

• Drooping of shoulders: absent

• Trachea: central

• Apex beat: not seen 

• No presence of any scar, sinuses or dilated veins.

• No use of accessory muscles of respiration

• No Supra or infra clavicular hollowness or fullness

• No drooping of shoulder

• No crowding of ribs 

• No wasting of muscles 

PALPATION:

• No local rise in temperature 

• Slight tenderness on the left 6th intercoastal space.

• All inspectory findings confirmed by palpation.

• Trachea : central- confirmed by three finger test. 

• Chest movements decreased on left side

• Apex beat:left 5th intercoastalspace 1cm to the medial to MCL

• Tactile vocal phremitus -decreased on left infra scapular.

AUSCULTATION:

• Bilateral air entry - present

• Decreased air entry on left infra mammary area, Infra axiallary area and infra scapulary area.

• Wheeze and coarse crepts present.

PERCUSSION:

• dull node is heard on the left Infrascapular area.

• Normal resonant node on the right side.

Cardiovascular system:

• S1 and S2 heard 

• No murmurs 

Per abdomen:

• All quadrants move symmetrically with respiration

• No presence of any scars and sinuses or engorged veins.

Central nervous system examination:

• intact 

• no focal neurological deficits.

INVESTIGATIONS:

On routine investigation:

Chest X Ray:

Ultrasound findings:

Bilateral grade 1 RPD 

Chronic cacific pancreatitis

Minimal ascites

provisional diagnosis:

DKA with consolidation in left lung

TREATMENT:

IVF -- NS and RL  100ml / hr continuos

Inj pantop 40mg /IV /OD

Inj augmentin 1.2gm/IV /BD

Tab dolo 650 mg/PO

Syp- ascoryl -p 10 ml/Po /tid

10ml -10ml - 10ml

GRBS charting 2nd hrly

Inj kcl 2 ampoules 

In 10 NS 

Over 4-5 hours