A 29 year old female came to opd with chief complainsts of cough and breathlessness

This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.



This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.





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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.


A 29 year old female, housewife resident of pedda devarapally nalgonda district, came to opd with chief complaints of fever , breathlessness and cough from past 10 days.



HISTORY  OF PRESENTING ILLNESS :
patient was apparently asymptomatic 10 days back,then she developed fever which was intermittent and aggravated during night.
Fever subsided on 3rd day.
She then started developing cough which was non productive.
 breathlessness which was initially grade 2 now progressed to grade 3 aggravated on lying down.
Patient also complains of diffuse chest pain of dragging type on cough.
On 4th day of illness she went to an RMP and received injections for 3 days,as her symptoms were not subsiding she was reffered to our hospital.
1/12/22: she arrived at our opd with severe breathlessness,chest pain which was dragging type non radiating diffuse pain associated with chest tightness and cough.
Breathlessness associated with wheeze, and sweating.
No h/o weight loss.
No h/o trauma.

Past history:
no h/o asthma and inhaler use.
No h/o tuberculosis
No h/o hypertension , diabetes 
No h/o heart diseases
No h/o cornary artery disease, peripheral vascular disease.
No h/o allergies to drugs, dust, pollen,specific food.

Personal History:

Diet: mixed

Appetite normal

Bowel and bladder movements: regular 

Sleep: disturbed,past 6 days she couldn't sleep properly  and gets up from bed due to breathlessness.

No addictions


Menstrual History: 

Age of menarche -12 yrs

Cycle- 3days of flow with 28 day cycle 

Not associated with pain and clots.

Lmp-1/11/22


Obstetric History: 

Age at marriage - 18yrs 

Age at first child birth- 19yrs

Para -2 (one male child in 1st delivery and one male+one female in 2nd delivery)

No. Of children -3  delivered  by LSCS 



Family History:

Not significant


DAILY ROUTINE 

She wakes up by 6 AM in the morning and do all her household works and have breakfast by 9 AM  and then prepares lunch by 12:30 .Eat  lunch at 1PM  and talks with neighbours after 4pm. Her kids and husband returns home by 5PM  and also she will have her fun time wwith kids and husband she will have her tea .prepares dinner at 7 pm and eats by 8pm , watch TV for one hour and Sleeps by 10pm.

   

 General physical examination:

Patient is conscious,coherent,cooperative. Moderately built and nourished.Well oriented to time ,place ,person.

Pallor-absent

Icterus - absent

Clubbing - Absent

Cyanosis- Absent

Lymphadenopathy- absent

Edema -  absent

 vitals:

On 1/12/22

Temperature: afebrile

Pulse rate : 144bpm

Respiratory rate : 42 cpm

Bp: 130/90 mmHg

Spo2 : 96 % at RA

GRBS : 151 mg %


On 4/12/22

Temperature- afebrile

BP:100/60 mmHg

PR:116 bpm

RR:26cpm

SPO2 : 98% at Room atmosphere 

GRBS : 112 mg/dl

On 5/12/22

Temperature- afebrile

BP:110/70mmHg

PR:110 bpm

RR:30cpm

SPO2 : 98% at Room atmosphere 

GRBS : 116 mg/dl

EXAMINATION OF RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACK

oral cavity: oral hygiene maintained

no ulcers,no dental caries,

No tonsillars hypertrophy

Nose:no DNS,NO POLYPS.
No congestion on posterior pharyngeal wall.


LOWER RESPIRATORY TRACK

Inspection:
Position of trachea- central
Chest - symmetrical
shape- elliptical
depth of movement - reduced on left side
Spino scapular distance - Incresed on left side.
RR:30(tachypnea)
Accessory muscle usage - present
No drooping of shoulders,wasting of muscles

Palpation:
Trachea -central
TVF-  reduced on left 
reduced in the Infrascapular area,
interscapular area,
inferior clavicular area,
mammary area,
inferior axillary area.
Reduced chest movements in infra SA,ISA,IAA.
Apex beat - not felt

Percussion:
Dull on left side over infra SA,ISA,IAA

AUSCULTATION:
Reduced breath sounds on left over infra SA,ISA,IAA.

SUCCUSSION SPLASH is absent on 5th dec

Investigations:
USG chest :- 
Chest x ray



 



 


PRESENT DAY ICD



CBP:- 







 Liver function test

ECG:- 

THORACOSTOMY FINDINGS:
ICD :
On 1/12/22
Tube - patent 
Drain - 200ml
Air column - 3.4cms
Air leak +
Subcutaneous emphysema-
On 2/12/22
Tube - patent 
Drain-nil
Air column movement : 3-4 cm H20
No subcutaneous emphysema 
Air leak absent  

Post procedure Vitals:
PR 128bpmBP 120/70mmHgRR 36 cpmSPO2 99%at RA

ECG FINDINGS: T wave inversion in v3 lead 

Provisional diagnosis:
Left sided hydro pneumothorax.

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