A 35 year old with sob and chest pain

January 04, 2023

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

A 35 year old female , resident of miryalaguda,store worker by occupation. Came to opd with chief complaints of :-

Fever since 11 days

Cough since 8 days

Breathlessness since 8 days and chest pain since 8 days

History of presenting illness:- patient was apparently asymptomatic 10 days back then she developed fever, insidious in onset,low grade, continous in nature, no diurnal variation, not associated with chills and rigor,relieved on medication.

She developed cough along with fever,insidious in onset, gradual progressive, sputum present, mucopurulent in nature, blood tinged (8-10 episodes) for 2 days subsided with medication, no seasonal, diurnal and postural variations.

Along with cough she developed,breathlessness, insidious in onset, grade 2 MMRC, no postural variations, aggravated on exposure to cold air and dust,seasonal variations present.

Chest pain since 8 days,left sided, dull aching type of pain, aggravated on coughing and lying to right side.got admitted to other hospital on 26 december( with chest pain, cough and breathlessness) , where she was on nebuliser for 2 days then she got discharged. Then after 2 days she again had the symptoms for which she was referred to our hospital, and got admitted on 3rd january.

No history of chest tightness, palpitations, burning micturition, loss of weight, and loss of appetite.

Past history:- similar complaints in past i.e , no history of hypertension, diabetes, she has history of usage of formeteral fumarate and Budesonide inhaler 2 puffs and asthaline once monthly.

Personal history:- diet- mixed, bowel and bladder movements -regular, appetite-normal, sleep is inadequate since 8 days due to chest pain. No addictions present. Food taboos present for brinjal.

Menstural history:- history of abnormal uterine bleeding for which hysterectomy was done 2 years back

Allergic history:- not allergic to any food or drug, allergic to dust

Family history:- no history of contact with presumptive TB patients.

General examination

Patient is consious, coherent and cooperative, moderately built and nourished.

No pallor, icterus, cyanosis, clubbing, no generalised lymphadenopathy. No generalised edema.

Vitals:- temperature:- Afebrile

Pulse rate :-

Respiratory rate:- 22cpm

Blood pressure:- 130/80 mmHg

SpO2:- 98%

Respiratory system examination:-

Upper respiratory tract examination:-

Nose :- no dns

Oral cavity:-good oral hygeine, no loss of tooth, caries

Lower respiratory tract examination:-

Inspection:- shape of chest:- elliptical, bilateral symmetrical chest, trachea appears to be in centre,no supraclavicular and infraclavicular hollowness , chest movements equal on both sides, no chest retractions, spinoscapular distance appears to be equal on both sides. Apical impulse not visible, no scars, sinuses and engorged vein, no kyphosis and scoliosis.

Palpation:- no local rise of temperature, no tenderness. Trachea is centre, apex beat -left 5th intercostal space medial to midclavicular line.

Tactile vocal fremitus decreased on left infrascapular area, interscapular area, mammary area, infra axillary area

Measurements:- AP :- 30 cms, transverse:- 34 cms

Chest circumference:- on inspiration -113 cm, on expiration :- 110 cm

Right hemithorax:- 55cm left hemithorax:-56cm

Percussion:-direct - resonant, indirect -impaired note in left infrascapular area, interscapular area,infra axillary area.

Auscultation:-bilateral air entry present, absent breath sounds in infrascapular area, vocal resonance decreased on left infrascapular area, inferior axillary area and mammary area.

Cvs examination:-Cvs examination:- on inspection shape of chest normal, no visible pulsations, no engorged veins present.

Palpation:- apex beat over left 5th intercostal space medial to midclavicular line. Jvp not elevated, no parasternal heaves

Auscultation:- s1 and s2 heard no murmurs heard.

CNS examination:- no neurological deficits

Abdominal examination:- no organomegaly

Provisional diagnosis:- pleural effusion secondary to acute exacerabation of asthma?? TB? Viral pneumonia??

Investigations:-On 3-1-2023