68YRS WITH LEFT UPPER LOBE CONSOLIDATION ?TB WITH PLEURAL EFFUSION WITH CAD - NSTEMI WITH CKD

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::

 Patient  daily wage worker by occupation came with c/o
FEVER SINCE 20 DAYS
COUGH since 20days
Loss of appeptite since 10days
Shortness of breath since 10 days
Weight loss since 2months

History of present illness::

Patient was apparently asypmtomatic 20 days back then she developed fever which was low grade not associated with chills and rigor ,continous not releived on medication 
Cough since 20days productive scanty sputum non blood stained non foul smelling
Loss of appetite since 10 days no H/o vomitings,abdominal pain ,loose stools ,giddiness Loss of weight 5-7kgs in 4weeks
Shortness of breath since 10days insidious gradually progressive from grade 1 to 2
Left sided chest pain since 1month non radiating spasmodic type 


Past History::

Known case of DM type 2 since 8yrs on medication on( insulin HAI)
Not a known case of HTN,CAD,CVD,EPILEPSY,TB,BRONCHIAL ASTHMA
Underwent S/P lap cholecystectomy (i/v/o cholelithiasis 4yrs back
Underwent S/P hysterectomy 25yrs back 

Family history::
 Not significant 


 Daily routine:: patient is a daily wage worker by occupation wakes up at 6am cooks food and has breastfast at 8am mostly jowar ghatka and goes for work mostly agricultural works and takes lunch at 1pm mostly rice with curries and at evening she takes tea at 5-6pm and cooks food for dinner and does dinner at 8pm mostly jowar roti and sleeps at 9pm.

Family history::
 Not significant 

Personal history::
 
Diet: mixed
Sleep ::   adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions::Nil(occasionally takes  toddy)

General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

pallor present 
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
 No Edema 


Vitals

Temperature::99.3f
PR-110bpm
Bp-150/90 mmhg
RR--18cpm

Local examination::




Respiratory system::
Inspection::

B/L symmetrical 
Trachea appears to be central
Supraclavicular and infraclavicular hallowing absent
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles absent
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

Percussion::

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

                                             RT.           LT .

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

Auscultation::

 B/L air entry present 
On auscultation:: fine crepts heard in left upper lobe  


PER ABDOMEN::

Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
No Tenderness present
No palpable mass 
No free fluid
Liver not palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard:

Cardio vascular system:
Jvp -not raised
Apex beat felt in 5th ICS in mid clavicular line
S1s2 heard
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Chest xray PA view ::
Ecg::
2d echo::



USG ABDOMEN AND PELVIS::


USG CHEST::




Provisional dagnosis::

68YRS WITH LEFT UPPER LOBE CONSOLIDATION ?TB WITH PLEURAL EFFUSION  WITH CAD - NSTEMI WITH CKD .

Treatment::

1.Tab.Ecospirin Av 75/10
2.Tab.pcm 650 mg Tid
3.syp. ascoril ls 10ml/Tid



Comments

Post a Comment

Popular posts from this blog

61YRS WITH K/C/O BRONCHIAL ASTHMA AND K/C/O CAD UNDERWENT S/P PTCA

Image
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::   Patient came with c/o cough since 18months Shortness of breath since 1yr Chest tightness and epigastric pain since 1yr History of present illness:: Patient was apparently asymptomatic 18months back then he developed  cough insidious in onset gradually progressive,dry, ...
Read more

22YR OLD WITH VOMITINGS AND ICTERUS

Image
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:::  PATIENT CAME TO OPD WITH C/O VOMITINGS SINCE 1WEEK YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK HISTORY OF PRESENT ILLNESS:: PATIENT WAS APPARENTLY ASYMPTOMATIC 1WEEK AGO THEN HE DEVELOPED VOMITINGS 3-4 EPISODES/DAY WITH FOOD MATERIAL AS CONTENT, NON BILIOUS, NON BLOOD TING...
Read more

45 yr old male with shortness of breath

Image
Chief complaints::   A   45 year old man came to the casualty complaining of  shortness of breath since 10 days.and swelling of lower limbs since 10 days History of present illness::: ..He was apparently asymptomatic six years ago, then he had an episode of fever for which was admitted to the hospital. . He was diagnosed with malaria. .He was diagnosed with Diabetes Mellitus as well. Then, 3 years ago , he had an another episode of fever for which he consulted a physician  He was found to have Viral Pyrexia and was diagnosed with Hypertension. Then around 1 year ago , one morning he had an episode of weakness of the right arm for which he was advised to undergo physiotherapy.  After 6 months of physiotherapy, the family thought he might get dependent on it so discountined. On September 2nd 2021, he came to the casualty with complaints of generalised swelling and shortness of breath since 10 days. Which was insidious in.onset gradually progressive from grad...
Read more