1701006101 CASE PRESENTATION
LONG CASE
15 year old male patient who is a student by occupation came to the OPD with the chief complaints of
Chest pain in the left side since 3 months
Difficulty in breathing since 15 days.
History of Present illness:
Patient was apparently asymptomatic 3 months ago then he developed chest pain on the left side which is insidious in onset, gradually progressive and is of dragging type,non radiating. It is aggravated during walking or doing some work and relieved on taking rest.
Patient complaints of difficulty in breathing since 3 months which was intermittent initially and is increased during the past 15 days.(MRCC- grade 1) Breathlessness is present after waking up from bed and then it decreases after some time. It is aggravated when the patient lies down in left lateral position and relieved when the patient lies down in right lateral position and upon sitting.
It was also associated with cough since 3 months which is intermittent and not associated with sputum.
Associated with fever since 3 months which is intermittent in nature and is of low grade, not associated with chills and rigor. It subsides on its own and patient did not use any medications.
Patient also complaints of fatigue since 2 months.
With these complaints he went to the local hospital and also consulted orthopaedician where no abnormality detected.
Later he went to another hospital where his chest x-ray and CT scan were done. Then he was admitted in the hospital for 7-10 days where he was given O2 supplementation and saline infusion. Then his symptoms got relieved and he was discharged.
After 10 days of discharge, he again developed chest pain on the left side, so he consulted another doctor where he was diagnosed with hydropneumothorax.
Chest pain and difficulty in breathing increased during the last 10 days hence he came to our hospital.
There is no history of PND,orthopnea,palpitations,vomitings, hempotysis, or trauma.
Past history:
Time line of events--
Patient is not a known case of HTN, DM, TB, asthma, epilepsy, CAD and any thyroid abnormalities.
Personal history:
Appetite - normal
Diet - mixed
Bowel and bladder- normal micturition , complaints of constipation since 2 years. Passage of hard stools for every 3-4 says.
Sleep- adequate.
Addictions- No
Allergies - No
Family history:
No significant family history.
General examination:
Patient is examined in a well lit room with informed consent
Pateint is conscious, coherent,co operative well oriented to time, place and person. She is moderately built and moderately nourished.
Pallor: present
No icterus, cyanosis, clubbing, generalised lymphadenopathy, edema.
Vitals:
PR- 76bpm
RR- 18 cpm
BP-110/70 mmhg measured in sitting postion in the right arm
Temperature -98.6 F
Spo2- 96% on room air
Systemic examination -
Respiratory system
Inspection:
Shape - elliptical
No tracheal deviation
Chest bilaterally symmetrical
Expansion of chest- normal
Breathing is abdominal thoracic
Use of accessory muscles - no
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
There is no local rise of temperature and tenderness
All the Inspectory findings are confirmed
trachea- present centrally
Apex beat- 5th intercoastal space, 1 cm lateral to midclavicular line.
Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
Measurements:
Anteroposterior length: 20cm
Transverse length: 28cm
Right hemithorax: 38cm
Left hemithorax: 36cm
Circumference: 74cm
Percussion:
Dull note heard at the left infraaxillary and infrascapular areas
Liver dullness from right 5th intercostal space
Auscultation:
Bilateral air entry present.
Vesicular breath sounds heard.
Decreased intensity of breathe sounds heard in infrascapular region and absent breathe sounds in left infraxillary area.
Vocal resonance: decreased in left infraaxillary and infrascapular areas.
ABDOMEN EXAMINATION
INSPECTION:
Shape – scaphoid
Flanks – full
Umbilicus –everted
All quadrants of abdomen are moving with respiration.
No dilated veins, sinuses, hernial orifices are free
No visible pulsations.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion of liver for liver span
Percussion of spleen- dull note
AUSCULTATION:
Bowel sounds are normal.
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
There is no precordial bulge
Apical impulse is present in left 5 th intercoastal space.
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs.
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - intact
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Superficial reflexes and deep reflexes are present , normal
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated .
Provisional diagnosis:
Mild left sided hydropneumothorax
Investigations:
Chest x- ray: Resolved hydropneumothorax
CT scan
USG report:
ECG:
Bronchoscopy:
Treatment:
On admission (4-6-2022)
1. High flow oxygen inhalation facemask
2. Plan for ICD placement
3. Monitor vitals.
4. ICD should be placed immediately for worsening of SOB.
5.Monitor vitals.
10-6-2022
Patient was sent for bronchoscopy.
After the procedure , patient was advised with-
1.NBM for 2 hours.
2. Sips of water was taken at 12:00 noon.
3. Soft diet was started at 2:00 pm.
4: T. PCM 650 mg
5. Inj. Neomol i. V BD, (PCM infusion)
6. Neb. With Duolin tid, budecort, mucomyst.
7. Chest physiotherapy.
8. Monitor vitals .
A 47 year old female who is tailor by occupation resident of nalgonda came to the OPD with the chief complaints of
Fever since 3 months
Facial rash since 10 days.
History of Present illness:
Patient was apparently asymptomatic 3 months back then she developed
Fever-- Insidious in onset, Intermittent -on and off ,not associated with chills and rigor. Relieved on medication . But she developed reccurent episodes of fever since then.
Then she latter developed facial rash since 10 days, which increased on exposure to sun. It was a diffuse erythematous lesion initially then became hyperpigmented. They were noted over the bilateral cheeks sparing nasolabial folds,following intake of unknown medication for abdominal pain. It is associated swelling of the left leg with erythema, and local rise of temperature.
There is no history of vomitings, abdomina pain, difficulty in breathing, palpitations or trauma.
Timeline of events--
Patient was apparently asymptomatic 11 years ago then,
She has diminision of vision 11years ago (since 2011 ).
|
And then she was certified as blind
|
Later after few months she developed bilateral knee and ankle joint pains and also pain in both the hands, for which she consulted the doctor and was diagnosed with Rheumatoid arthritis. (There was swelling associated with pain and morning stiffness for about 15mins associated with limitation of movements).Then she used medications for Rheumatoid arthritis -- diclofenac.
|
Then she was apparently asymptomatic
|
In 2021 she took covid vaccination after which she developed post vaccination joint pains for which she consulted orthopaedician. She was prescribed with some pain killers and her symptoms got relieved.
|
Then later she again complained of joint pains associated with fever 3 months ago (in March,2022).
Fever-- Insidious in onset, Intermittent -on and off ,not associated with chills and rigor. Relieved on medication . But she developed reccurent episodes of fever since then.
|
Then she latter developed facial rash since 10 days, which increased on exposure to sun. It was a diffuse erythematous lesion initially then became hyperpigmented. They were noted over the bilateral cheeks sparing nasolabial folds,following intake of unknown medication for abdominal pain.
Past History:
Patient was certified as blind in 11 years ago.
Patient presented with similar complaints of joint pain and fever in the past for which she took medication.
She is not a k/c/o diabetes, TB, asthma, epilepsy, CAD or thyroid abnormalities.
Personal History:
APPETITE:Decreased
Diet. Mixed
BOWEL AND BLADDER MOVEMENTS ; regular
SLEEP; disturbed since 10 days
ADDICTIONS : no addictions.
Family history:
There are no similar complaints in the family.
General examination:
Patient is examined in a well lit room with informed consent
Pateint is conscious, coherent,co operative well oriented to time, place and person. She is moderately built and moderately nourished.
Pallor: present
No icterus, cyanosis, clubbing,lymphadenopathy, edema.
Vitals:
PULSE :86BPM
BP:120/80mm hg
RR:16cpm
SPO2:98%at room air.
Local examination:
Face- on inspection
Hyperpigmented patch is present on both the cheeks and around the lips sparing the nasolabial folds.
Left lower limb swelling was present at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt
SYSTEMIC EXAMINATION:
ABDOMEN EXAMINATION
INSPECTION:
Shape – elliptical
Flanks – full
Umbilicus –everted
All quadrants of abdomen are moving with respiration.
No dilated veins, sinuses, hernial orifices are free
No visible pulsations.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion of liver for liver span
Percussion of spleen- dull note
AUSCULTATION:
Bowel sounds are feeble.
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse seen
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 1cm away from the midclavicualar line.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is seen.
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper/mid/lower interscapular were all RESONANT.
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - intact
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Superficial reflexes and deep reflexes are present , normal
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated .
Provisional diagnosis:
Secondary Sjogrens syndrome with bilateral optic atrophy and left lower limb cellulitis.
INVESTIGATIONS
TREATMENT
1.INJ PIPTAZ 4.5 gm IV/ TID.
2.INJ METROGEL100 ML IV/TID
3.INJ NEOMOL1GM/IV/SOS
4.TAB CHYMORAL FORATE PO/TID
5.TAB PAN 40 MG PO/ OD.
6.TAB TECZINE10 MG PO/OD
7.TAB OROFERPO/OD.
8.TAB HIFENAC-P PO/OD
9HYDROCOTISONE cream 1%on face for 1week.
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