General Medicine -14

A 26 YEAR OLD FEMALE CAME WITH SHORTNESS OF BREATH AND CHEST PAIN.

This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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 a diagnosis and treatment plan. 

CASE SHEET:

Chief complaints:

A 26 year old female, hailing from nakerekal, agricultural worker by occupation, came with chief complaints of:

- generalised weakness since 15 days back

- fever 15 days back

- Shortness of breath since 6 days

History of present illness:

The patient was apparently asymptomatic  15 days back. She then developed generalised weakness during her routine work , which subsided on rest.

Then 15 days back, she developed fever, which was associated with chills and rigors at earling morning, which was subsided on medication with paracetamol and fever was recurring if medication was not taken.

10 days back, she then developed cough which was non productive cough, associated with left sided chest pain, which was not relieved on medication.

6 days back, she then developed Shortness of breath of ( grade III ), which was aggrevated on doing daily routine work. She also developed Shortness of breath after she woke up from bed which lasted for a few minutes.

She  then developed night sweets, yesterday night.

No history of body pains, vomitings, headache, hemoptysis.

Past history:

No history of Diabetes mellitus, hypertension, thyroid disorders, epilepsy, coronary artery diseases.

Personal history:

Diet: Mixed

Bowel : regular

Micturition: normal

Appetite: decreased

Habits: nil

No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:

Insignificant

General examination:

Pallor present

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No malnutrition

No dehydration

No pedal edema 

VITALS:

Temperature: 98.6 F

Pulse: 80 beats per minute, irregular

Respiratory rate: 16 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 96%

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:

Shape of chest: flat shape

Symmetry: hollow on supraclavicular region on right side

Respiratory movements: tachypnea

Rhythm: regular

Type: thoracoabdominal

Palpation:

Position of trachea: Central

Vocal fremitus: increased on left side

Tenderness: absent

Percussion:

Dullness on left side of the chest

Auscultation:

Breath sounds: vesicular

Intensity: reduced on left side

Additional sounds: wheeze is present

Cardiovascular system:

No thrills

murmurs: systolic murmur

Cardiac sounds: S1, S2 heard

Abdomen:

Shape of abdomen: scaphoid

No tenderness

No Palpable mass

Non palpable liver

No Palpable spleen

No bruits

Bowel sounds: heard

Central Nervous System:

Conscious

Speech: normal

Investigations:

Provisional Diagnosis:

Left upper lobe Pneumonia.