Hall ticket no 1801006183

 Short Case

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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 diagnosis and treatment plan.

CHIEF COMPLAINTS:

A 77 yr old male resident of nalgonda came to opd with chief complaints of cough since 20 days , fever since 10 days , breathlessness since 5 days , altered sensorium since 2 days .

HISTORY OF PRESENTING ILLNESS :

patient had a CVA 7 yrs back , he had left hemiplegia and was bed ridden and he was on ryle’s tube for feeding .

Now patient presented with cough initially dry cough for 1 week now since 5 days he has productive cough with sputum which is yellow in color. Fever since 10 days which is high grade , intermittent and not associated with chills and rigor ,since 5 days he has continuous fever .Breathless ness since 5 days ,patient’s attender noticed this breatheless compared to his previous breathing pattern ,altered sensorium since 2 days. NO history of hemoptysis. NO history of nasal discharge , sore throat .

PAST HISTORY: 

Patient had a cva 7 yrs back resulting left hemiplegia for which he underwent treatment.

He is a known case of diabetes since 2 years.

He is a known case of Hypertension since 10 years.

No History of asthma, thyroid, epilepsy, TB, congenital heart disease.

General Examination:

Patient is conscious, coherent, cooperative, with altered sensorium

Pallor - present

Icterus- absent

Cyanosis- absent

Clubbing- absent

No lymphadenopathy

No pedal edema

Vitals

Temperature- 101 F

Pulse- 110

BP- 140/80 mm Hg

SpO2- 95%

RR- 24 cpm

GRBS- 210 mg/dl

SYSTEMIC EXAMINATION

Respiratory System:

Inspection:

Shape and movement of the chest are normal

Trachea is central

Palpation

Trachea is midline

chest movements equal on 

both sides 

Apex beat - felt in the left 5th ICS

Increased vocal fremitus seen in right scapular, infra scapular axillary, infra axillar

Percussion

On percussion dullness noted in the right scapular, infra scapular axillary, infra axillary

other areas are resonant

Auscultation:

decreased breath sounds in the right scapular, infra scapular axillary, infra axillary

other areas- Normal vesicular breath sounds heard.

Fine crepitations heard

Increased vocal resonance

CNS

No focal neurological deficits.

Altered sensorium present.

Power    Right         Left

U/L            5/5        3/5

L/L            5/5         3/5

Tone        Normal  Increased

         

Reflexes

Babinski’s sign - left side positive

CVS

S1 S2 heard

No murmurs heard

GIT

Soft, non tender

No organomegaly

Normal bowel sounds heard

Investigations

Xray

Blood urea -30mg/dl

HBA1C-6.7%

HIV 1/2 RAPID TEST - NON REACTIVE

Anti HCV antibodies rapid - nonreactive

TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)

Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)

Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)

Electrolytes -

Sodium 135meq/l

Potassium 3.5 meq/l

Chloride 98meq/l

Calcium -1.06 mmol/l

 

PROVISIONAL DIAGNOSIS

Right middle and lower lobe Pneumonia.