15yr old male with chest pain and breathlessness

Final exam - long case



Name : M.Tejaswini
Hallticket no: 1701006107

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-centered online learning portfolio and your valuable inputs on the comment box.



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




PER ABDOMEN:

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
bronchoscopy report
Chest xray:
CT scan of chest



Treatment:
-IV normal saline
-high flow O2 inhalation with face mask.
-Tab paracetamol 650mg



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