lung collapse

Hello all this is J. Mounika, a eighth semester student.This E Log depicts the patient centered approach to learning

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

80 year old male with  cough and difficulty in breathing since 2 years 

An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with 
CHIEF COMPLAINTS of cough and difficulty in breathing since 2 years, which  aggravated since 2 months 

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 2 years ago then he had complaints of shortness of breath which was insidious on onset and gradually progressive , initially it was MMRC grade I to MMRC grade IV 
No associated wheeze 
No orthopnea 
No seasonal variations, no pnd 
No history of recurrent upper/ lower respiratory tract infections 
Also complaints of cough since 2 years 
Associated with sputum, copious in amount, mucopurulent, yellowish colour, foul smelling
Not associated with blood
Cough aggravated on lying down
No seasonal variations 
No chest pain, palpitations, syncopal attacks 

PAST HISTORY 
K/C/O TB 30 years back, used medication for 4 months 
K/C/O HTN since 5 months 
N/K/C/O DM, CAD, Asthma , epilepsy 

PERSONAL HISTORY 
Diet mixed 
Appetite Normal 
Bowel and bladder movements regular
Sleep adequate 
Addictions Alcohol and smoking which was stopped 40 year ago

GENERAL EXAMINATION 
Patient is c/c/c , moderately built and nourished 
No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy, pedal edema 
Vitals:
Temp- afebrile 
PR- 78bpm
BP- 110/70 mmhg 
RR- 18cpm
SpO2- 97% at RA 


SYSTEMATIC EXAMINATION 
RESPIRATORY SYSTEM EXAMINATION 
URT
Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 
Dental caries present 
Nose - No septal deviation or Nasal polyps 

LRT
1.INSPECTION 
Shape of the chest - elliptical 
There is drooping of shoulder towards left side
Trachea appears to be central 
Equal movement of chest wall on both sides
No usage of  accessory muscles 
No scars ,sinuses ,engorged veins, edema 

2.PALPATION 
No local rise of temperature  , no tenderness 
Trachea deviated towards the left side
Movement of chest wall - slightly decreased on left side 
AP diameter is 22cm and Transverse diameter is 28 cm
Chest circumference -
On inspiration- 86.cm
On expiration - 86cm
Tactile fremitus -     right         left  
Supraclavicular                       increased 
Infraclavicular                          increased 
Mammary                                 increased
Axillary                                      increased 
Infra axillary                             increased
Suprascapular                          increased
Infrascapular                           increased
Interscapular                           increased

Vocal resonance -
                                   Right         left 
  Supraclavicular      Normal   increased
  Infraclavicular        Normal   increased
  Mammary               Normal   increased 
  Axillary                   Normal    increased 
  Infraaxillary            Normal    increased 
  Suprascapular       Normal    increased 
  Infrascapular         Normal    increased 
  Interscapular         Normal    increased 
  
3. PERCUSSION 
                                 Right       left 
 Direct                   Normal     decreased 
 Supraclavicular   Normal      decreased 
 Infraclavicular     Normal      decreased 
 Mammary            Normal      decreased 
 Axillary                Normal      decreased 
 Infra axillary        Normal      decreased 
 Suprascapular   Normal        decreased 
 Infrascapular     Normal        decreased 
 Interscapular     Normal        decreased

Investigations:


Provisional diagnosis:
LEFT COLLAPSE OF LUNG
k/c/o BRONCHIAL ASTHMA
k/c/o HYPERTENSION

Treatment:

17/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID

18/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly IPRAVENT 6th hrsly

19/10/2023
-Inhaler formoterol and budesonide 2 puffs/ SOS
-T. TELMA 40 mg PO/OD
-syp.ASCORIL -LS 10 ml/ PO/ TID
-Neb. with BUDESONIDE 12th hourly IPRAVENT 4th hrsly


Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSIGNMENT FOR JUNE 2021

 Jella Mounika Roll No: 51 Batch: 2019( 3rd Semester)   I have been given the following assessment to analyze and review, in an attempt to understand the topic of patient 'clinical data analysis' to develop my competency in reading. This is the link regarding assessment:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 QUESTION 01: competency tested for review and assessment Reviewing 10 answers in the link given above.  CASE 01: NEUROLOGY Link: https://aniganikavya06.blogspot.com/ The case was diagnosed as cerebellar ataxia secondary to the cerebrovascular accident which was supported by the patient's chief complaints of slurring of speech, deviation of mouth.              Cerebellar ataxia is due to blockage in the brain which causes decreased blood supply because of that, Oxygen and nutrients to the cerebellum are reduced which ultimately leads to ataxia in the cerebellum.  Patient hypertension and alcoholism have al
Read more

Prefinal OSCE

1.RR in tachypnea?  -The normal respiratory rate (RR) for adults at rest is typically in the range of 12 to 20 breaths per minute. Tachypnea is generally defined as a respiratory rate that exceeds this normal range,  that is respiratory rate higher than 20 breaths per minute in adults considered tachypneic. 2.why there is tachypnea in community acquired pneumonia (CAP)despite a normal SpO2 reading of 99% ?  Reasons for tachypnea in CAP: Ventilation-Perfusion Mismatch: Pneumonia can lead to a mismatch between ventilation (airflow) and perfusion (blood flow) in the lungs. Even with adequate oxygen levels in the inhaled air, the exchange of gases in the affected areas of the lungs may be compromised, triggering a respiratory response. Increased Work of Breathing: The body's effort to overcome the decreased lung function and maintain sufficient oxygen supply to the bloodstream can result in tachypnea, despite the overall oxygen saturation appearing normal. 3.Respiratory findings in Com
Read more

GM - Elog

Image
Name : J. Mounika  Roll no :  51 3rd sem student  This is an online e log book to discuss our patient de- identified health data shared after taking his/ her guardians signed and informed consent.  I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. Case presentation: A 50 year old male, farmer , resident of nagarjunsagar came with OPD with decreased urine output and shortness of breath.  History of present illness •Pedal edema since 3 months • Facial puffiness, decreased urine output since 3 months •shortness of breath since  3 days History of past illness Pt was apparently asymptomatic 3 months back, was admitted & Diagnosed as chronic renal failure with anemia • Dialysis initiated on 15/10/2021, 4 session of HD done, 20 PRBC transferred.  Tre
Read more