(LONG CASE)A 70yr old with SOB and COUGH

(LONG CASE)FINAL MBBS PART 2 
KNRUHS
PRACTICAL EXAMINATION.
1701006180

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment

Chief complaints ::

A 70YR OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF SHORTNESS OF BREATH SINCE 20days. COUGH since 20days

History of present illness::

 SHORTNESS OF BREATH since 20 days which was insidious in onset gradually progressive
Grade 2-3 according to MMRC not associated with orthopnea , paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,relieving on rest,aggrevating on working.

COUGH since 20 days insidious onset ON AND OFF productive with mucoid sputum non foul smelling,not blood stained, no nocturnal and diurnal variation , relieved on medication

No H/o wheeze,chest pain, palpitations
 H/o loss of weight(5kg in last month)
H/o loss of appetite

Past history::

H/o similar complaints in past 10 yrs back 
No H/o Diabetes, hypertension,asthma ,CAD,seizures.

Family history::

 No H/o respiratory diseases in family

Personal history::
 
Diet:mixed
Sleep :: adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions:: alcoholic since 50 yrs (daily 250 ml whisky)
                      Smoking since 50 yrs( daily 3_4 beedies)
Stopped smoking since 10 yrs

Treatment  history::

H/o ATT  taken previously 10 yrs back
No allergies to drug,food

General examination::

After taking consent patient examined in a well lit room

Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Thin built, nourishment moderate

Mild pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
No edema

Vitals..
Pulse:102bpm
Bp:130/80 mm of hg
Temperature::afebrile
RR:16c/min

Systemic examination::

Respiratory examination:::

Inspection::

B/L symmetrical and elliptical
Trachea appears to be central
Supraclavicular and infraclavicular hallowing present
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles present
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 5th ICS in mid clavicular line
Tactile vocal fremitus ..right side decrease in IAA area

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::

                                             RT.           LT .

Supraclavicular.         Resonant.    Resonant
Infraclavicular.           Resonant.     Resonanat
Mammary.                  Resonant.    Resonant
Inframammary.          Resonant.     Resonanat
Axillary                        Resonant.      Resonant
Infraaxillary.                Dullness.        Resonanat
Suprascapular.           Resonant.      Resonant
Interscapular.             Resonant       Resonant
Infrascapular.             Dullness.        Resonant

Auscultation::

 B/L air entry present
Normal vesicular breath sounds heard
Decreased breath sounds in Infra axillary Areas,Infra Scapular areas
 Vocal resonance ::decreased in InfraAxillaryArea,InfraScapular area

Per abdomen::

Soft non tender
Scaphoid
No organomegaly
Bowel sounds normal
No sinuses scars engorged veins
No palpable mass

Cvs::

JVP not raised
S1 S2 heard
No murmurs
No precordial bulge

Cns::

Conscious 
Speech normal
Cranial nerves ::intact
Motor system::normal
Sensory system ::Normal
Reflexes :: normal+5on both Rt,Lt side

Investigations:::

X-ray chest PA view
11/06/22
12/06/22

Complete blood picture::

 Hemoglobin.8.6gm%
Total leucocyte count 4100
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count 2.45lakh/mm3

Complete urine examination::
pale yellow urine
Clear
Rbcs nil
Casts nil

Liver function tests::

Total bilirubin:0.43 mg/dl
Direct bilirubin:0.14 mg/dl
Aspartate Transaminase:23 U /L
AlaninePhosphatese:165 U /L
Alanine Transaminase:11 U /L
TotalProteins:6.7g/dl
Albumin/GlobulinRatio:0.89

Renal function tests::

Urea:33 mg/dl
Creatinine:1.2 mg/dl
Uric acid:5.6 mg/dl

Serum electrolytes::

Na+::133 mEq/L
K+::4.2 mEq/L
Cl-::45 mEq/K

Pleural fluid ::

Sugar::150mg /dl
Protein::5.5gm/dl
Ldh::134.4Iu/L
Total count:1500cells/mm3
DLC:: Lymphocytes::80%
          Neutrophils::20%

Pleural fluid PROTIENS/ serum proeins:::5.5/6.7=0.82

Provisional diagnosis::

 Right sided Pleural effusion secondary to Tuberculosis

Management::



 





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