Final Exam Short Case

Hall ticket number:1601006042

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

CASE :

A 14yr old male who is a student resident of Nalgonda came with chief complaints of -

1) Fever since 8days

2) Cough since 8days

3) Shortness of breath since 8days

History of present illness :

Patient was apparently asymptomatic 8 days back then 

- He developed fever,insidious in onset, continuous,low grade associated with chills and rigor and relieved on medication

- History of cough which was insidious in onset ,not associated with expectoration and no aggravated and relieving factors.

- History of shortness of breath,which is insidious in onset,progressed from grade1 to grade 2 (MMRC),aggravated on exertion and relieved on sitting position.

RESPIRATORY SYSTEM EXAMINATION :

Inspection :

-Trachea central

-Expansion of chest decreased on left side

Palpation:

-Trachea central in position

-Expansion of chest decreased on left side

-Vocal fremitus  diminished in Interscapular , infrascapular ,infraaxillary on left side.

Percussion :

-Dull note on left Interscapular , infrascapular , infraaxillary area on left side.

Auscultation:

- diminished breath sounds on left side

- diminished vocal resonance in left infrascapular area, infraaxillary area and Interscapular area

Investigations :

Chest X ray

Provisional diagnosis :

Left sided pleural effusion