1701006200 CASE PRESENTATION
LONG CASE:
15 YEAR OLD MALE CAME TO OPD WITH CHEIF COMPLAINTS OF:
Left sided chest pain since 3months.
Breathless ness since 3months.
Fever since 2months.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months back ,later he developed chest pain since 3 months which is insidious in onset ,dragging type of pain,gradually progressive, which is aggravted on lying down position and relived on sitting position.
Breathless ness since 3months which is not associated with cough ,sneezing aggravted on lying down position.
Cough is present occasionally without expectoriation.
Fever since 2months mostly on night time ,low grade intermittent fever not associated with chills, relieves on medication.
PAST HISTORY:
7years back he developed weakness and pain all over the body for which he went to the local hospital and treated conservatively.
4 years back again he had similar complaints where is was treated conservatively.
2 years back he was diagnosed with herpes
NO H/O DM, HTN, ASTHMA, CAD, EPILEPSY, THYROID DISORDERS.
PERSONAL HISTORY:
Diet:mixed diet
Sleep:adequate
Appetite: Normal
Bowel and bladder movements: constipation present.
No known addictions and allergies.
GENERAL EXAMINATION:
Patient was consious ,coherent,cooperarive ,moderately built and well nourished.
There are no signs of
Pallor,icterus,clubbing,cyanosis,lymphadenopathy, kolinochyia.
Vitals:
Temperature: 98.6⁰F
Blood pressure: 100/60mmof hg
Pulse rate-78bpm
Respiratory rate-18cpm
Spo2 97% at room air O2.
SYSTEMIC EXAMINATION :
Cvs: S1 and S2 are heard
No murmurs .
Respiratory system:
Inspection:
Shape of the chest: bilaterally symmetrical and elliptical
Rate and rythm of respiration: 18cpm with regular rythm
Symmetry of the chest exoansion : equal on both sides
Movements of the chesst wall : normal
Palpation :
Palaption of the apex beat and trachea
Trachea midline and can be palpated at sulra sternal notch
Apex beat : palpated in the 5th intercoastal space intthe mid clavicular line
Expansion of the chest : symmetrical expansion.
Vocal fremitus: equal in intensity
Percusion:
There is no dull note
Auscultation:
Vesicular breath sounds heard all over the chest
It is a low pitching rusting sound
There is no gap betwwen inspiration and expiration
Bronchial breath sounds only heard at trachea
No abnormal sounds like rhonchi ,crepitations,pleural rub
Per abdomen :
INSPECTION:
Shape if the abdomen : scaphoid
Umblicus: midline and invereted
No signs of scars ,sinuses
No engorged veins are seen
PALPATION:
There is no local rise of temlerature
Abdomen is soft ,non tender
No organomegaly.
PERCUSSION :
NO fluid thrill is present.
AUSCULTATION:
Bowel sounds are heard.
INVESTIGATIONS:
HEMOGRAM: 12g/dl
TLC: 11000cell/mm³
Sputum smear microscopy for TB: negative.
CBNAAT : -ve
ECG: normal
USG:
No right sided pleural effusion..
Chest x ray-
CT SCAN:
PROVISONAL DIAGNOSIS:
A 15 year old male was diagnosed with left sided hydro pneumothorax & right basal pneumothorax.
TREATMENT:
High flow O2 inhalation with face mask.
Plan of ICD placement.
Monitor vitals.
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SHORT CASE:
A 25 year old female patient who is a housewife and resident of Miryalaguda came to OPD with
Chief complaints:
General check up in measuring bp found to be150/100mmof hg
HISTORY OF PRESENTBILLNESS
2021:1st pregnancy:When patient conceived visited obstetrician and on examination found to have Hypertension(150/100 mmHg)
Started on Labetalol PO BD
At around 8 months:intrauterine death,baby delivered by NVD
Stopped antihypertensives
2022:patient conceived again,blood pressure 160/100 mmHg started on labetalol 100mg BD
At 8 months: preterm delivery live baby NVD died within one day
NEGATIVE HISTORY:
No H/O chest pain palpitations shortness of breath
No H/O of pedal edema
NoH/O decreased urinary output
No H/O seizures
No H/O headache blurring of vision
PAST HISTORY:
Diagnosed with hypertension during first pregnancy
first pregnancy: intrauterine death at 8th month
She had hyperemesis during first pregnancy in the first trimester
Second pregnancy: baby delivered at 8 th month normal vaginal delivery and died with in one day
Not a known case of diabetes Mellitus, TB, asthma, thyroid disorders , epilepsy
No past surgical history
No blood transfusions done
Menstrual history:
Age of menarche: 13 years
28 day cycle regular bleeds for 3 days
Associated with back ache
Not associated with clots
Marital history:
Married in 2020 non consanguineous
Personal history:
Occupation : house wife
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder: regular
No addictions
Family history:
Not significant
General examination:
Patient is conscious coherent and cooperative
well oriented to time place and person moderately built and nourished.
Height :161cm
weight:58kg
BMI:22.3kg/m2
No pallor
icterus
cyanosis
clubbing
generalised lymphadenopathy
edema
BP:170/100 mmHg
Respiratory rate:22cpm
Temperature: afebrile
SpO2: 98%
Systemic examination:
CVS
Auscultation:S1 S2 sounds heard
no murmurs and
no added sounds
Abdominal examination:
Inspection
Shape scaphoid
Umbilicus inverted
No visible gastric peristalsis
Hernial orifices free
Palpation
soft ,non tender ,no organomegaly
Bowel sounds heard on auscultation
Respiratory system :
Inspection
trachea central in position
Chest movements symmetrical
Auscultation:
BLAE present
NVBS heard
Investigations:
A 23 year old female diagnosed with Young onset hypertension
Treatment:
1) Tab.AMLONG 5mg PO/OD
2) Tab.ZINCOVIT PO/OD
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