Short case - practicals

Hall ticket number : 1701006160

Short case 

       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 options

Following is the view of my case :

A 15 year old with chest pain 

A 15 year old male resident of west Bengal came to OPD with 

C/O : 

1. Chest pain since 3 months 
2. Shortness of breath since 1 month 

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 3 months back then he developed

1. chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning towards left side. Pain relieved on sitting. First the parents thought it as acidity and gave medication for it and not relieved.
2. Pain was severe 3 months ago for which patient took medicines, the following month he didn't complain of severe pain. The pain aggravated last month for which they visited the doctor. After investigations they couldn't find any abnormality. 
3. No history of palpitations, PND, pedal edema, vomiting, hemoptysis, trauma.
4. Shortness of breath since 1 month, grade 2 (MMR). Insidious in onset, gradually progression, aggravated on lying down and on lying on left side. Relieved on sitting. Associated with dry cough
5. Not associated with wheeze and cold, fever, sore throat, headache.

PAST HISTORY : 

-No similar complaints in the past

-7yrs back patient had complaints of body pains for which he was managed conservatively

-4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital

- 2 yrs back he developed herpes on left side of face.

-No history of DM, HTN, TB, Asthma, epilepsy

PERSONAL HISTORY : 

Diet : mixed

Appetite : normal

Sleep : adequate

Bowel/Bladder : regular

Addictions : nil 

FAMILY HISTORY : 

Not significant 

GENERAL EXAMINATION : 

Patient is explained about the examination and consent taken. 

-Patient is conscious, coherent, cooperative 

-No signs of pallor, Icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 

VITALS: 

Pulse rate    : 75 bpm

Respiratory rate  : 17cpm 

Blood pressure  : 120/70 mm of Hg 

Temperature : afebrile 

RESPIRATORY EXAMINATION : 

Inspection : 

-Shape of chest - elliptical 

-No tracheal deviation 

-Chest bilaterally symmetrical

-Expansion of chest-  equal on both sides

-Use of accessory muscles - not present 

-No dilated veins,pulsations,scars, sinuses.

Palpation : 

-No local rise of temperature and tenderness

-trachea- central

-Apex beat- 5th intercoastal space,medial to mid clavicular line.

-Vocal fremitus- decreased on left side in infra axillary region.

Measurements:

-Anteroposterior length : 13.5cm

-Transverse length : 27cm

-Circumference : 78cm

Percussion : 

-dull note heard at the left infra axillary area. 

Auscultation : 

-Bilateral air entry present. 

-Vesicular breath sounds heard. 

-Decreased intensity of breath sounds heard in left infra axillary area

-Vocal resonance: decreased in left infra axillary  area

CVS EXAMINATION : 

-S1and S2 heard, no murmurs 

ABDOMINAL EXAMINATION : 

-soft non tender 

-no organomegaly

CNS EXAMINATION : 

-Sensory and motor system normal

INVESTIGATIONS : 

PROVISIONAL DIAGNOSIS : 

-Left side hydropneumothorax 

 

TREATMENT : 

-Tab.paracetomol

-IV fluids