General Medicine Final Practical - Short Case

Gnana Prasuna Reddy K.

1701006069

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.

71 year old male with breathlessness

Chief complaints-

A 71 year old male , labourer by occupation,  came to the general medicine OPD  on 1st June 2022 with chief complaints of

Breathlessness since 20 days

Cough since 20 days

Fever since 4 days

History: 

Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1)  and dry cough.

2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.

20 days back breathlessness progressed to MMRC grade-2 to 3

.Associated with wheeze

.Aggrevated on cold exposure,exertion

.Relieved on rest

.No orthopnea and PND

20 days back,he developped cough with expectoration

.Mucoid in consistency

.Non foul smelling

.Non blood stained

.Aggrevated at night

4 days back,he developped fever,which is continuous and low grade 

.Evening rise of temperature is present

.Relieved on medication

.Not associated with chills and rigors

History of past illness-

.No history of similar complaints in the past

.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.

Personal history-

.Diet-mixed

.Appetite-decreased since 2 months

.Sleep-adequate

.Bowel and bladder movements are regular

.Addictions-smoking since 2yrs (4 beedies per day)

  Drinks toddy from 22yrs of age (1 litre per day)

.Stopped smoking and alcohol intake since 2 months.

Family history-

.Not significant

General examination-

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

He is thin built and moderately nourished.

.Weight-34 kgs

.Temperature-99°F

.Pulse rate-83 beats per minute

.Respiratory rate-20 cycles per minute

.BP-120/80 mm of hg

.SpO2-95%at room air

.GRBS-108mg/dl

Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- absent

.Lymphadenopathy- absent

.Edema- absent

Systemic examination-

Respiratory system-

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No kyphosis and scoliosis

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No drooping down of shoulders

.No intercoastal indrawing

Palpation-

.All inspectory findings are confirmed

.No local rise of temperature and tenderness

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

.AP diameter-30cm

.Transverse diameter-23cm

.Hemithorax diameter on right side is  less than that on the left side.

Percussion-

.Dull note heard on right upper part of chest

.vocal fremitus- reduced on apical part of right side of chest

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe 

.crepitations present on right mid axillary area

.Vocal resonance- reduced on right apical area

CVS-

.S1 and S2 heard

.No murmurs

P/A examination:

.Soft,non tender,no organomegaly

.Bowel sounds- heard

CNS

.Speech- normal

.cranial nerves- normal

.Motor system- normal

.Sensory system- normal

.Reflexes-normal

.Gait- normal

Provisional diagnosis-

Right lung upper lobe fibrosis

Investigations-

CBP-

CUE-

LFT-

2D echo-

HRCT-

HBS-Ag-

HIV- 

Hepatitis-C-

AFB Culture-

RFT-

.Urea-31 mg/ dl

.Creatinine-0.9

.Uric acid-3.1

.calcium- 10

.phospate-3.3

.sodium-128

.chlorine-95

.potassium-4.2

ABG-

.pH-7.44

.pCO2-34.3

.pO2 -68.3

.HCO3-23.4

Needle thoracocentasis was done on 5 th June,2022.

.Under ultrasound guidance

.Fluid aspirated was 20 ml 

.Straw coloured

Final diagnosis-

Right lung upperlobe fibrosis

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD