A CASE OF 34 YEAR OLD MALE WITH CHEST TIGHTNESS AND SOB SINCE 4 DAYS
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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 in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan.
CHIEF COMPLAINTS -
Cough since 5 days
SOB since 5 days
Pain in epigastric region
HOPI -
- The patient was apparently alright five days ago after which he developed dry cough which was insidious in onset ,cough increased in the night ,associated with chest tightness and pain in the left chest area.
- Shortness of breath developed which was insidious in onset and gradually progressive from grade 1 to grade 4 ( MMRC). SOB aggravated on sitting, walking and decreased on lying in left lateral position
- Pain in the epigastric region which is insidious in onset, dragging type, non-radiating pain, aggravated on taking food and water and decreased on medication, bending down .
- Belching, bloating present
- No c/o nausea, vomiting, loose stools, malena
- No c/o burning micturition , decreased or increased urine output
- No c/o chest pain, palpitations
History of past illness -
k/c/o DM since 6 months and not on any medication currently ( used medication for 10 days and stopped 6 months ago)
Not a K/C/O HTN, TB, asthma, CAD,CVA epilepsy
No surgical history
No h/o previous hospital admissions
PERSONAL HISTORY
Married
Occupation - AUTO DRIVER
Appetite - Normal
Mixed dietBowels movements – Regular
Micturition - Normal
Known Allergies - No
Habits / Addictions:
Alcohol-Occasional - Toddy 1 Glass Since 13 year.
FAMILY HISTORY
Father is diabetic
GENERAL PHYSICAL EXAMINATION
No Pallor , Icterus ,Cyanosis ,Clubbing of fingers/toes, Lymphadenopathy ,Oedema of feet
No Malnutrition ,Dehydration
Temperature – 93.6 °F
Pulse Rate 94 beats / min
Respiratory Rate 30 cycles /min
BP - 130/100 mm/Hg
SPO2 at Room air - 99% /
GRBS 128 mg%
SYSTEMIC EXAMINATION -
CVS -
S1, S2 heard
No thrills, murmurs
RESPIRATORY SYSTEM
Dyspnoea - Present
No Wheeze
Position of Trachea - Shifted to Right
Breath Sounds – Vesicular , low Breath sounds on left side.
No Adventitious Sounds
PER ABDOMEN-
Soft , non tender
No organomegaly
CNS -
No focal neurological deficit
DETAILED RESPIRATORY EXAMINATION -
Upper respiratory tract -
No halitosis
hygiene maintained
No oral thrush
No pharyngeal deposits
Tonsils normal
Dental carries – Absent
Septum - Normal
Turbinate hypertrophy - Absent
No nasal polyps
Sinus tenderness – Absent
Lower respiratory tract
Inspection : Chest is asymmetrical shape
Trachea appears to be central
Trial sign – Absent
Apical impulse - Not visible.
Respiratory movements better appreciated on right side
No dropping of shoulder
Supra clavicular hollow right side
Infra clavicular hollow - Absent
No intercoastal fullness indrawing, rotation ,widening
No crowding of ribs
No Scorbutic/ Rachaetic rosary
No Harrisons sulcus , No pectus carinatum / excavatum
No Kyphoscoliosis , winging of scapula
No scars , sinuses , dilated veins, nodules
No use of accessory muscles of respiration
Palpation :
All inspectory findings are confirmed.
Trachea midline
No tracheal tug
Measurements:
Circumference of left hemithorax is 51 centimetres
Right hemithorax is 50 centimetres.
AP -26 centimetres
Transverse - 31.5 centimetres
Apical impulse- not felt
Chest movements decreased on left side in upper, lower zone
Chest expansion in whole left hemithorax less than right hemithorax
Tactile vocal fremitus – Decreased on left side
Percussion: Right Left
Clavicular Resonant. Dull
Khrogis isthmus. Resonant. Dull
Infraclavicular. Resonant. Dull
Mammary. Resonant. Dull
Infra axillary. Resonant. Dull
Supra scapular. Resonant. Dull
Infra scapular. Resonant. Dull
Inter scapular. Resonant. Dull
No percussion tenderness
Auscultation:
No added sounds
Traube’s space obliterated on left side
Breath sounds. Right Left
NVBS. Normal. Decreased
Vocal Resonance. Normal decreased
Bronchophony. Normal decreased
Egophony. Normal. decreased
Whispering better heard in left side
Pectoriloquy - Normal. Decreased
Succession splash - Absent
PROVISIONAL DIAGNOSIS -
MASSIVE LEFT SIDED PLEURAL EFFUSION 2° to ? TUBERCULOSIS
INVESTIGATIONS -
ECG-
On the day of admission 9/5/24- X RAY CHEST PA VIEW
GRBS CHARTING -
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