A 15 YEAR OLD MALE WITH CHEST PAIN AND BREATHLESSNESS
Long case
Hall ticket no:1701006126
June 10th 2022
15yr old male with chest pain and breathlessness
June 10, 2022
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A 15yr old male patient came with the complaints of:
-Chest pain since 3 months
Fever since 2 months
-Breathlessness since 1 month
History of present illness
Patient was apparently asymptomatic 3 months back then he developed chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning on left side. Pain relieved on sitting.
No history of papitations, PND, pedal edema, vomiting, hemoptysis, trauma.
Then he developed fever which was intermittent,low grade,more at night,not associated with chills and rigors,and rot relieved with fever
Then he developed breathless since 1 month grade I(MRSA) Insidious in onset, persistent in nature, aggrevated on lying down and on lying on left side. Relieved on sitting.
Associated with dry cough
Not associated with wheeze
No history of fever, loose stools
Past history
No similar complaints in the past
7yrs back patient had complaints of body pains for which he was managed conservatively
4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital
2 yrs back he developed herpes on left side of face.
No history of DM, HTN, TB, Asthma, epilepsy
Personal history
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder regular
No addictions
No known drug and food allergies
Family history
Not significant
General examination
Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
temperature:99.3F
Pulse rate: 78bpm
Resp rate:18cpm
BP:110/70mmhg
Spo2:98%
Systemic examination
Respiratory system
Inspection:
Shape - elliptical
No tracheal deviation
Chest bilaterally symmetrical
Expansion of chest- normal
Use of accessory muscles - no
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No local rise of temperature and tenderness
Inspectory findings confirmed
trachea- normal
Apex beat- 5th intercoastal space,medial to midclavicular line.
Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
Measurements:
Anteroposterior length: 13cm
Transverse length: 28cm
Circumference: 78cm
Percussion:
Dull note heard at the left infraaxillary and infrascapular area
Auscultation:
Bilateral air entry present.
Vesicular breath sounds heard.
Decreased intensity of breath sounds heard in left infraxillary and infra scapular area
Vocal resonance: decreased in left infraaxillary and infrascapular areas
PER ABDOMEN:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion - tympanic note heard
Auscultation- normal bowel sounds heard
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest- elliptical
No precordial bulge or pulsations
JVP - not raised
Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard No murmurs
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Provisional diagnosis
Mild left sided hydropneumothorax
Chest xray:
CT scan of chest
Treatment:
-IV normal saline
-high flow O2 inhalation with face mask.
-Tab paracetamol 650mg