60 /M presented with complains of left side chest pain, fever, loss of appetite
January 01, 2023
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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 .
CHIEF COMPLAINTS:
Fever since 13 days
Chest pain on left side since 10 days
Loss of appetite since 10 days
HOPI:
Patient was apparently asymptomatic 8 months back , then he developed fever which was high grade , intermittent, associated with chills and rigor ,no diurnal variation, relieved with medication. Cough which was initially dry and then progressed to productive cough with scanty sputum, which was white coloured, non foul smelling, non blood stained.
Bronchoscopy was done and diagnosed with right lower lobe aspergilloma and started on Itraconazole 200 mg BD for 6 months. Patient recovered symptomatically and was fine till 13 days back .
13 days ago, patient developed fever , which is of low grade , intermittent, no diurnal variation, not associated with chills and rigor .Chest pain which was of sudden onset 10 days ago , which is increasing with respiration and chest movements associated with palpitations and excessive sweating. Patient also has SOB which was initially of grade 2 and later progressed to grade 3 . Orthopnea is present.Patient was evaluated and found to have LV Strain , tall T waves and was treated symptomatically.
Loss of appetite since 10 days and bilateral pedal edema , pitting type extending till knee.
PAST HISTORY:
Right lower lobe aspergilloma on Tab. Itraconazole 200mg PO/BD
Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB
PERSONAL HISTORY:
Appetite-Decreased
Diet - Mixed
Bowel and bladder - regular
Sleep - Decreased.
General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Pedal edema - pitting type extending till knee
VITALS : Temp - 98.6 F
PR - 62 bpm
BP - 120/80 mmhg
RR - 25 cpm
SPO2 - 98% onRA
GRBS - 102 mg/dl
Systemic examination:
PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration
No scars , sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpitation :
Abdomen is soft and non tender
No organomegaly.
Percussion :
Tympanic note heard over the abdomen.
Auscultation:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpitation:
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Investigations :
CBP :
Hb – 14.3 gm/dl
TLC – 7300cells/cu mm
Neutrophils : 56
Lymohocytes : 29
Eosinophils : 07
Monocytes : 08
Platelets – 2.40 lakh/cu mm
Serum albumin - 3.37 gm/dl
CUE :
Albumin -
Pus cells - 2-3/HPF
Epithelial cells - 2-3/HPF
RENAL FUNCTION TESTS :
Urea : 26 mg/dl
Creatinine : 0.6 mg/dl
Sodium : 132 mEq/L
Potassium : 4.4 mEq/L
Chloride : 101 mEq/L
LIVER FUNCTION TESTS :
Total bilirubin : 1 mg/dl.
Direct bilirubin : 0.23 mg/dl
AST : 33 IU/L
ALT : 37 IU/L
Alkaline phosphate :208 IU/L
Total proteins : 5.3gm/dl
Albumin : 3.67 gm/dl
A/G ratio : 1.75.
CHEST X RAY:
2D ECHO :
