A 35 year old female presented with shortness of breath and chest pain

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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 ODP with chief complaints of

• fever since 11days

•cough since 8days

• breathlessness since 8days

•chest pain since 8days

History of presenting illness

patient was apparently asymptomatic 11 days back then she developed fever which was insidious in onset, continuous,low grade associated with chills and rigor,no diurnal variation relieved on medication. 

She also developed cough 8days ago which was insidious in onset, gradual progressive, productive ,mucopurulent in nature ,non foul smelling,blood tinged sputum(8-10 episodes)for 2days subsided with medications, no seasonal, diurnal and postural variations and relieved on taking medications.

Patient also developed breathlessness 8days ago  which was 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, non radiating, aggravated on coughing and increases  on lying to right side. 

No history of sore throat,chest trauma

No history of orthopnea,pnd.

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

She 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. 

Past history

No similar complaints in the past

History of asthma since 6years for which she uses formeteral and budesonide inhaler 

No history of hypertension, diabetes, tuberculosis, thyroid abnormalities

 

Personal history

Diet-mixed

Appetite -normal

Sleep- inadequate since 8days due to chest pain

Bowel and bladder-regular

Addictions-no

Menstrual history

History of abnormal uterine bleeding for which hysterectomy was done 2years ago

Allergic history

No food allergic and drug allergy 

Family history 

No history of contact with presumptive TB patients

General examination

Patient is conscious, coherent and cooperative moderately built and nourished

No pallor, icterus, clubbing ,no generalized lymphadenopathy no generalized edema

Vitals:

 temperature:- Afebrile

Pulse rate :- 82bpm
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 -dull note in left infrascapular area, interscapular area,infra axillary area. 

Auscultation:-

bilateral air entry present, decreased breath sounds in infrascapular area,infra axillary area

 
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 exacerbation of asthma?? Viral pneumonia?? Tuberculosis?? 

Investigations

Complete blood picture

Hb-11.6gm/dl

Total count_12,800

Neutrophils -70%

Lymphocyte-20%e

Eosinophils -2%

Monocytes-8%

Basophils-0%

Platelet count-4.24

Smear-normocytic normochromic blood picture with leucocytosis 

Serum electrolytes

Sodium-136mEq/L

Potassium -4.3

Chloride-103

Calcium ionized-0.94

ABG-normal

Liver function test

Total bilirubin -0.73mg/dl

Direct bilirubin-0.19

SGOT - 32IU/L

SGPT- 31

Alkaline phosphatase-147

Total proteins-7.8

Albumin-3.42

A/Gratio-0.78

Uric acid -3mg%

Blood urea-24mg/dl

serum creatinine -0.7

Serology -negative

Hiv1&2-negative

HbsAg -negative

HepBAg- negative

Anti HCV ab-non reactive

Sputum CBNAAT - negative(28/12/2022)

On5-01-2023 

CBP

PREVIOUS REPORTS 

ON 28.12.2022

ON 2-01-2023

DIAGNOSIS

Non resolving pneumonia with left lower lobe consolidation with signs of pleural effusion     ?CAP

Treatment 

Nebulizer with ipravent 6hrly

  Nebulizer with budecort 8th hrly

Monitor vitals

T.Montek -LC OD

Inj.ceftriasone 1gm IV BD

Inj.pan 40mg IV OD

Inj neomol/100ml

T.PCM 650mgPO TID

Syp. ascoril 2tsp TID