Final practical long case
A.Bhavani
Hallticket.no-1701006004
Batch-2017
June 7th,2022
This is 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 patients 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 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 diagnosis and treatment plan.
71 year old male with breathlessness
Chief complaints-
A 71 year old male ,Mason 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
Daily routine-
He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.
Timeline-
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 was progresses 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 movements-regular
.Bladder movements-decreased flow of urine since 15 days associated with burning sensation
.Addictions-smoking since 2yrs (4 beedies per day)
Drinks toddy from 22yrs of age (1 litre per day)
.Stopped smoking and toddy ntake since 2 months.
Family history-
.No history of similar complaints in the family members
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 supraclavicular and infraclavicular hollowing
.No intercoastal indrawing
Palpation-
.All inspectors 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-23cm
.Transverse diameter-30cm
.Hemithorax diameter on right side is less than that on the left side.
.vocal fremitus reduced on apical part of right side of chest
Percussion-
.Dull note heard on right upper part 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
Per abdominal examination-
.Shape of the abdomen- scaphoid
.Hernial orifices- normal
.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 upperlobe fibrosis
Investigations-
CBP-
CUE-
LFT-
2D echo-
ECG-
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
=>2/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 102 bpm
RR-26 com
SpO2-90% on RA
98% on 2 lit oxygen
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
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
=>03/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 89 bpm
RR-26 com
SpO2-96% on RA
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
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
8).syp.Cremaffin-1ml HS
04/06/2022-
O/E - patient is conscious, coherent, cooperative.
Temperature-98.7°F
BP-120/80 mmHg
PR- 94 bpm
RR-14 com
SpO2-92% on RA
96% on 2 litres oxygen
Respiratory system examination-
Bilateral air entry- present
No added sounds
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
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
05/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 90 bpm
RR-24 com
SpO2-96% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
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
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
06/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
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
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
07/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
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
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
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