MEDICINE CASE DISCUSSION
A 15 YEAR OLD MALE WITH HYDROPNEUMOTHORAX.
Shows minimal hydropneumothrax in left side of lung.
PROVISONAL DIAGNOSIS:
Y.Navya Sahithi reddy
Roll no: 1701006200
March 13th 2022
This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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's clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed .
I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
CHEIF COMPLAINTS:
Left sided chest pain since 3months.
Breath less ness since 3months.
Fever since 2months.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months back ,later he developed chest pain since 3 months which is insidious in onset ,dragging type of pain,gradually progressive, which is aggravted on lying down position and relived on sitting position.
Breathless ness since 3months which is not associated with cough ,sneezing aggravted on lying down position.
Cough is present occasionally without expectoriation.
Fever since 2months mostly on night time ,low grade intermittent fever not associated with chills, relieves on medication.
PAST HISTORY:
7years back he developed weakness and pain all over the body for which he went to the local hospital and treated conservatively.
4 years back again he had similar complaints where is was treated conservatively.
2 years back he was diagnosed with herpes
NO H/O DM, HTN, ASTHMA, CAD, EPILEPSY, THYROID DISORDERS.
PERSONAL HISTORY:
Diet:mixed diet
Sleep:adequate
Appetite: Normal
Bowel and bladder movements: constipation present.
No known addictions and allergies.
GENERAL EXAMINATION:
Patient was consious ,coherent,cooperarive ,moderately built and well nourished.
There are no signs of
Pallor,icterus,clubbing,cyanosis,lymphadenopathy, kolinochyia.
Vitals:
Temperature: 98.6⁰F
Blood pressure: 100/60mmof hg
Pulse rate-78bpm
Respiratory rate-18cpm
Spo2 97% at room air O2.
SYSTEMIC EXAMINATION :
Cvs: S1 and S2 are heard
No murmurs .
Respiratory system:
Inspection:
Shape of the chest: bilaterally symmetrical and elliptical
Rate and rythm of respiration: 18cpm with regular rythm
Symmetry of the chest exoansion : equal on both sides
Movements of the chesst wall : normal
Palpation :
Palaption of the apex beat and trachea
Trachea midline and can be palpated at sulra sternal notch
Apex beat : palpated in the 5th intercoastal space intthe mid clavicular line
Expansion of the chest : symmetrical expansion.
Vocal fremitus: equal in intensity
Percusiion
There is no dull note
Auscultation:
Vesicula breath sounds heard all over the chest
It is a low pitching rusting sound
There is no gap betwwen inspiration and expiration
Bronchial breath sounds only heard at trachea
No abnormal sounds like rhonchi ,crepitations,pleural rub
Per abdomen :
INSPECTION:
Shape if the abdomen : scaphoid
Umblicus: midline and invereted
No signs of scars ,sinuses
No engorged veins are seen
PALPATION:
There is no local rise of temlerature
Abdomen is soft ,non tender
No organomegaly.
PERCUSSION :
NO fluid thrill is present.
AUSCULTATION:
Bowel sounds are heard.
INVESTIGATIONS:
HEMOGRAM: 12g/dl
TLC: 11000cell/mm³
Sputum smear microscopy for TB: negative.
CBNAAT : -ve
ECG: normal
USG:
No right sided pleural effusion..
Chest x ray-
CT SCAN:
PROVISONAL DIAGNOSIS:
A 15 year old male was diagnosed with left sided hydro pneumothorax.
TREATMENT:
High flow O2 inhalation with face mask.
Plan of ICD placement.
Monitor vitals.
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