This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
FINAL MBBS PART-2 KNRUHS EXAMINATION
Roll number: 1701006195
CHIEF COMPLAINTS
A 70 year old male, resident of Nalgonda and farmer by occupation came with the chief complaints of
1. Shortness of breath since 20 days
2. Cough since 20 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 years ago when he developed shortness of breath, which was insidious in onset and gradually progressive from MMRC grade II to III (SOB on walking 100m). The shortness of breath was not associated with cough, fever or chest pain.
Because of this, the patient went to a local doctor who, on performing investigations, advised him to go to a higher centre.
In arriving at the tertiary care hospital, he was diagnosed with pleural effusion due to TB and treated with antitubercular therapy. However, he took the medication for only 3 months, following which his symptoms were relieved and he stopped the medication.
20 days ago, he developed shortness of breath again, which was insidious in onset and gradually progressive, from grade II to grade III MMRC. It was aggravated on working, relieved on taking rest. There was no orthopneoa, paroxysmal nocturnal dyspnoea, and no diurnal variation.
He also noted cough since 20 days, which was insidious in onset, intermittent in nature, with 4-5 episodes per day, productive in nature. The sputum was mucoid, noun foul smelling, non blood srained. No aggravating or relieving factors were noted.
Loss of weight was noted, with him losing 5kgs in the last 6months. He also noted a loss of appetite in the last 20 days, and would only eat curd rice.
Symptoms were not associated with chest pain, palpitations, fever.
DAILY ROUTINE
Patient wakes up in the morning around 6am, following which he eats breakfast. After this, he usually goes to work in the fields and comes back home around 6 in the evening. In the last month, the patient continued to work as a farmer, however, his work was hindered by his shortness of breath as he would have to take breaks in between to catch his breath.
PAST HISTORY
Similar complaints 10 years ago, wherein he was diagnosed with TB and partially treated.
No history of diabetes, hypertension, asthma, epilepsy.
PERSONAL HISTORY
Diet: Mixed
Appetite: Decreased since 20 days
Sleep: Adequate
Bowel and bladder: Regular
Addictions:
-Alcohol consumption since 50 years (daily 250ml whisky)
-Smoker since 50 years (daily3-4 beedies)
No known food or drug allergies
FAMILY HISTORY
No similar complaints in the family
GENERAL EXAMINATION
Performed after taking consent of patient, and in a well lit room.
Patient is conscious, coherent, co-operative and well oriented to time, person, place.
Thin built, moderately nourished.
Patient examined in supine position.
Pallor present
No signs of icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
VITALS
HR: 80 beats per minute
BP: 120/80mmHg
RR: 16 cycles per minute
Temperature: Afebrile
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Upper Respiratory tract:
Nose: No DNS, polyps, hypertrophy of turbinates
Good oral hygiene
Pharynx normal
INSPECTION:
Shape of chest: Elliptical, bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular hollowing present
Wasting of muscles present
Spinoscapular distance normal
No crowding of ribs
No drooping of shoulder
No kyphosis, scoliosis
No visible scars, sinuses, pulsations, engorged veins
PALPATION:
No tenderness, local rise of temperature
Inspectory findings confirmed
Normal expansion of chest on both sides in all areas
Chest diameter: 5:7
Position of trachea: Central
Tactile vocal fremitus: decreased in R. Inframammary, infra axillary, infrascapular areas
Apex beat: felt in 5th intercostal space medial to midclavicular line
PERCUSSION:
Direct: over clavicle- Resonant
Indirect:
Right. Left.
Supraclavicular. Resonant. Resonant.
Infraclavicular. Resonant. Resonant.
Mammary. Resonant. Resonant.
Inframammary. Dullness. Resonant.
Axillary. Resonant. Resonant.
Infraaxillary. Dullness. Resonant.
Suprascapular. Resonant. Resonant.
Interscapular. Resonant. Resonant.
Infrascapular. Dullness. Resonant.
AUSCULTATION:
Decreased vesicular breath sounds in R. Inframammary, infra axillary, infrascapular areas. NVBS heard in other areas
Vocal resonance: decreased in R inframammary, infraaxillary, infrascapular areas
CARDIOVASCULAR SYSTEM:
On palpation,
-Apex beat localised in 5th ICS, medial to midclavicular line
-JVP normal
-No precordial bulge
-No parasternal heave
On auscultation, S1, S2 heard; no murmurs
PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted
Bowel sounds heard
CENTRAL NERVOUS SYSTEM:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION-
Normal sensations felt in all dermatomes
MOTOR EXAMINATION-
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES-
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION-
Normal function
No meningeal signs were elicited
EVALUATION
CXR PA VIEW:
Taken on 11/6/22:
Taken on 12/6/22:
ECG:
COMPLETE BLOOD PICTURE:
Hb: 8.6gm/dl (decreased)
TLC: 4100/mm^3
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count: 2.45lakh/mm^3
COMPLETE URINE EXAMINATION: Normal
LIVER FUNCTION TESTS:
Total bilirubin: 0.43 mg/dl
Direct bilirubin: 0.14 mg/dl
AST: 23 U/L
ALP: 165 U/L
ALT: 11 U/L
TP: 6.7g/dl
A/G: 0.8
RENAL FUNCTION TESTS
Urea: 33mg/dl
Creatinine: 1.2 mg/dl
Uric acid: 5.6 mg/dl
SERUM ELECTROLYTES
Na+:133 mEq/L
K+: 4.2 mEq/L
Cl-: 96 mEq/L
PLEURAL FLUID ANALYSIS:
Sugars: 151mg/dl
Protein: 5.5g/dl
TLC: 1525 cells
DLC: Lymphocytes 80%
Neutrophils 20%
ADA: 12 U/L
PROVISIONAL DIAGNOSIS:
Right sided pleural effusion secondary to exudative cause
TREATMENT PLAN:
-Inj. Augmentin 1gm IV TID
-O2 with nasal prongs to maintain spO2 >94%
-Inj pan 40 IV OD
-Tab. MUCINAC TID
-Tab. PCM 650mg SOS
-Syrup Ascoril 2tbsp TID
-Tab. Orofer OD
-Monitor vitals
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