15yr old male with chest pain and breathlessness
Final exam - long case
Name : M.Tejaswini
Hallticket no: 1701006107
A 15yr old male patient came with the complaints of:
-Chest pain since 3 months
-fever since 2months
-Breathlessness since 1 month
History of present illness
Patient was apparently asymptomatic 3 months back then he developed chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning on left side. Pain relieved on sitting.
No history of papitations, PND, pedal edema, vomiting, hemoptysis, trauma.
Fever since 2 months, intermittent, low grade, more at night. Not associated with chills and rigors.it relieved with medication.
Then he developed breathless since 1 month grade I(MMRC) Insidious in onset, gradually progression, aggrevated on lying down and on lying on left side. Relieved on sitting.
Patient has weight loss(his clothes became loose) which was noticed by father
Associated with dry cough occasionally
Not associated with wheeze.
Past history
No similar complaints in the past
7yrs back patient had complaints of body pains for which he was managed conservatively
4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital
2 yrs back he developed herpes on left side of face.
No history of DM, HTN, TB, Asthma, epilepsy
Personal history
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder regular
No addictions
No known drug and food allergies
Family history
Not significant
General examination
Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
temperature:99.3F
Pulse rate: 78bpm
Resp rate:18cpm
BP:110/70mmhg
Spo2:98%
Systemic examination
Respiratory system
Inspection:
- Shape - elliptical
- No tracheal deviation
- Chest bilaterally symmetrical
- Expansion of chest- normal
- Use of accessory muscles - no
- No dilated veins,pulsations,scars, sinuses.
- No drooping of shoulder.
Palpation:
- No local rise of temperature and tenderness
- Inspectory findings confirmed
- trachea- normal
- Apex beat- 5th intercoastal space,medial to midclavicular line.
- Expansion of the chest is bilaterally symmetrical
- Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
- Measurements:
Anteroposterior length: 13cm
Transverse length: 28cm
Circumference: 78cm
Percussion:. Rt. Lf
Supraclavicular area. R. R
Infraclavicular area. R. R
Mammary area. R. R
Axillary area. R. R
Infraaxillary area. Dull. Dull
Suprascapular area. R. R
Interscapular area. R. R
Infrascapular area. Dull. Dull
Auscultation:
- Bilateral air entry present.
- Vesicular breath sounds heard.
- Supraclavicular area. N N
- Infraclavicular area. N. N
- Mammary area. N N
- Axillary area. N N
- Infraaxillary area. reduced
- Suprascapular area. N N
- Interscapular area. N N
- Infrascapular area. reduced
- Vocal resonance: decreased in left infraaxillary and infrascapular areas
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion - tympanic note heard
Auscultation- normal bowel sounds heard
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest- elliptical
No precordial bulge or pulsations
JVP - not raised
Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard No murmurs
CENTRAL NERVOUS SYSTEM:
Higher mental functions:intact
No signs of meningeal irritation.
Cranial nerves- normal
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: normal
Provisional diagnosis
left sided hydropneumothorax
Investigations:
Culture and sensitivity
Chest xray:
-IV normal saline
-high flow O2 inhalation with face mask.
-Tab paracetamol 650mg
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