Final Practical Short Case

Final Practical Short case 

Arushi kumari

Roll no. 151 

Hall ticket no. 1701006012

Mbbs 9th Sem

07/06/2022

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

I’ve 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.

71 year old male with breathlessness

Chief complaints-

A 71 year old male ,Mason by occupation came to the general medicine OPD  on 1st June,2022 with chief complaints of

. breathlessness since 20 days

.cough since 20 days

.fever since 4 days

I’ve 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.

71 year old male with breathlessness

Chief complaints-

A 71 year old male ,Mason by occupation came to the general medicine OPD  on 1st June,2022 with chief complaints of

. breathlessness since 20 days

.cough since 20 days

.fever since 4 days

I’ve 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.

71 year old male with breathlessness

Chief complaints-

A 71 year old male ,Mason by occupation came to the general medicine OPD  on 1st June,2022 with chief complaints of

. breathlessness since 20 days

.cough since 20 days

.fever since 4 days

Daily routine-

He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.

History of present illness-

Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1)  and dry cough.

=>2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.

=>20 days back breathlessness was progresses to MMRC grade-2 to 3

.Associated with wheeze

.Aggrevated on cold exposure,exertion

.Relieved on rest

.No orthopnea and PND

=>20 days back,he developped cough with expectoration

.Mucoid in consistency

.Non foul smelling

.Non blood stained

.Aggrevated at night

=>4 days back,he developped fever,which is continuous and low grade 

.Evening rise of temperature is present

.Relieved on medication

.Not associated with chills and rigors

History of past illness-

.No history of similar complaints in the past

.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.

Personal history-

.Diet-mixed

.Appetite-decreased since 2 months

.Sleep-adequate

.Bowel movements-regular

.Bladder movements-decreased flow of urine since   15 days associated with burning sensation

Addictions-smoking since 2yrs (4 beedies per day)

  Drinks toddy from 22 yrs of age (1 litre per day)

.Stopped smoking and alcohol intake since 2 months.

Family history-

.No history of similar complaints in the family members

General examination-

Patient is conscious, coherent , cooperative.well oriented to time, place and person

He is thin built and moderately nourished.

.Weight-34 kgs

.Temperature-99°F

.Pulse rate-83 beats per minute

.Respiratory rate-20 cycles per minute

.BP-120/80 mm of hg

.SpO2-95%at room air

.GRBS-108mg/dl

.Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- absent

.Lymphadenopathy- absent

.Edema- absent

Systemic examination-

Respiratory system-

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No kyphosis and scoliosis

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No usage of accessory muscles

Palpation-

.All inspectors findings are confirmed

.No local rise of temperature and tenderness

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

.AP diameter-

.Transverse diameter-

Percussion-

.Dull note heard on right upper part of chest

.vocal fremitus-equal on both sides

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe 

.crepitations present on right mid axillary area

CVS-

.S1 and S2 heard

.No murmurs

Per abdominal examination-

.Shape of the abdomen- scaphoid

.Hernial orifices- normal

.Soft,non tender,no organomegaly

.Bowel sounds- heard

CNS-

.Speech- normal

.cranial nerves- normal

.Motor system- normal

.Sensory system- normal

.Reflexes-normal

.Gait- normal

Provisional diagnosis-

Right lung upperlobe fibrosis

Investigations-

CBP-

CUE

LFT

2D echo

HRCT

ECG

HsbAg 

HIV

Hepatitis C

AFB culture 

RFT-

.Urea-31 mg/ dl

.Creatinine-0.9

.Uric acid-3.1

.calcium- 10

.phospate-3.3

.sodium-128

.chlorine-95

.potassium-4.2

ABG-

.pH-7.44

.pCO2-34.3

.pO2 -68.3

.HCO3-23.4

.Needle thoracocentasis was done on 5 th June,2022.

.Under ultrasound guidance

.Fluid aspirated was 20 ml 

.Straw coloured

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

>2/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 102 bpm

RR-26 com

SpO2-90% on RA

           98% on 2 lit oxygen

Respiratory system examination-

Crepitations- right midaxillary area

Decreased breath sounds on right side upper lobe

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

=>03/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 89 bpm

RR-26 com

SpO2-96% on RA

  

Respiratory system examination-

Crepitations- right midaxillary area

Decreased breath sounds on right side upper lobe

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

8).syp.Cremaffin-1ml HS

04/06/2022-

O/E - patient is conscious, coherent, cooperative.

Temperature-98.7°F

BP-120/80 mmHg

PR- 94 bpm

RR-14 com

SpO2-92% on RA

           96% on 2 litres oxygen

Respiratory system examination-

Bilateral air entry- present

No added sounds

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

8).syp.Cremaffin-1ml HS

9).Tab.Aceclofenac-BD

05/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 90 bpm

RR-24 com

SpO2-96% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds 

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

8).syp.Cremaffin-1ml HS

9).Tab.Aceclofenac-BD

10).Inj.optineurin-1 ampule

06/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 88 bpm

RR-22com

SpO2-98% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds 

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

8).syp.Cremaffin-1ml HS

9).Tab.Aceclofenac-BD

10).Inj.optineurin-1 ampule

11).Diclofenac patch

07/06/2022-

O/E - patient is conscious, coherent, cooperative.

BP-120/80 mmHg

PR- 88 bpm

RR-22com

SpO2-98% on RA

  

Respiratory system examination-

Bilateral air entry- normal

No added sounds 

            

Treatment-

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD

8).syp.Cremaffin-1ml HS

9).Tab.Aceclofenac-BD

10).Inj.optineurin-1 ampule

11).Diclofenac patch

Final diagnosis-

Right lung upperlobe fibrosis