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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 competency I reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Roll no 125
48 Year old male toddy climber by occupation resident of kattangur came with chief complaints of
Fever since 7 days
Cough since 4 days
Shortness of breath since 4 days
Chest pain since 1day
History of present illness
Patient complained of fever which was associated with chills relieved by medication.
4 days ago he also complained of cough without expectoration.
Cough is not relieved by taking cough syrup and there is positional variation of Cough which was increased by getting up from bed.
No history of hemoptysis
shortness of breath progressed from grade 3 to grade 4. Initially patient noticed Shortness of breath while walking over short distance now he complains during rest.
He could not perform his work due to breathlessness.
He also complained of left sided diffuse chest pain dragging type.
Pain aggrevates on coughing
Intensity of pain reduced by taking medication.
4 years ago History of similar episodes of fever and chills and got hospitalized where he was diagnosed with diabetes mellitus but on irregular medication.
He has history of seizures since 5 years 5 episodes in last 5 years.
Due to heavy alcohol intake he was hospitalized and was diagnosed with jaundice and fatty liver.
Last episode a year ago.
No history of orthopnea PND.
Past history
No history of Hypertension Tuberculosis Asthma CAD.
Family history
Not significant
Personal history
He takes Mixed diet
Appetite is normal
Bowel and bladder movements are regular
Addiction:Alcoholic since 20 years
Smoking- no
Clinical images
General examination
Patient is conscious coherent and coperative well oriented to time place and person
No signs of Pallor cyanosis clubbing lymphadenopathy
Icterus-+
Vitals
Afebrile
Bp 130/90
Respiratory rate 14 bpm
Pulse rate 72 bpm
Systemic examination
Respiratory system
INSPECTION
shape of the chest is elliptical
No drooping of shoulders
No Supraclavicular hollowness
No visible pulsation or scars
No crowding of ribs
PALPATION
Inspection findings are conformed
Restriction of movement on left side of chest.
Trachea and apex beat are normal in position
No tenderness
No local rise of temperature
Vocal fremitus increased on left side
Over only inframammary of left and interscapular areas
Supraclavicular
infraclavicular
Inframammary
Axillary
Infraaxillary
Suprascapular
interscapular
infrascapular
PERCUSSION dullness noted over left inframammary area and resonance is heard over right side of the chest.
AUSCULTATION
Normal vesicular breath sounds heard over right side..
Reduced vesicular breath sounds over left mammary region
No additional sounds heard
Vocal resonance increased left infrascapular area and remaining areas normal.
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness
No palpable mass
Liver not palpable
CNS EXAMINATION
Conscious ,alert
No motor deficit
No neck stiffness
No signs of meningeal irritation
Cvs examination
S1 s2 heard
No murmurs
Investigations
Provisional diagnosis
Diabetic ketosis secondary to sepsis
Irregular medication
Left Lower lobe consolidation
Treatment
Ivf RL NS
Inj Augmentin 1.2 gm iv tid
Inj Thiamine 1amp in 100 ml NS TID
Inj Zofer 4mg/iv/bd
Inj. Tramadol in 100 ml NS over 30 mins
Inj PCM
Syrp Benadryl 5ml/po/tid
Tab Cetirizine 5mg/po/od
Inj Azithromycin 500mg/po/bd
Update
Chest pain got reduced .
Cough got subsided
Sob only on talking not on rest
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