A 19years old female with complaints of cough with sputum

 

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I have been given this case 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.

A 19 year old girl studying 12th grade from devarakonda came to the GM OPD with

CHIEF COMPLAINTS - 

Cough with sputum from 5 days.

HOPI : 

Patient was apparently asymptomatic 5 days ago. Then she developed cough which was insidious in onset productive, mucopurulent discharge , Light green sputum , 2 episodes of blood stained sputum seen, Non foul smelling , Aggravated on exposure to cold environment relieved on medication , Sometimes had burning throat.

Then she developed fever which was insidious in onset , gradually progressive , high grade , continuous , not associated with chills and rigors , No evening rise of temperature, no Sweating , relieved on medication.

No H/O SOB , chest pain, chest tightness , loss of appetite , weight loss , palpitation, burning micturition, Wheeze present.

Past history :

Similar complaints of fever with cough and sputum 1 year ago ( about one week)

● H / O SOB on exertion , relieved on rest

● No orthopnea , PND

● H /O Hospital admission for this.

● No H/O inhaler usage

● No H/O TB, DM, HTN, CAD, epilepsy , thyroid

Family history:

Her sister had difficulty in breathing

Her sister died in the past after intake of poison

Social history:

She wakes up at 6am 

Goes to college at 9:30

She will have lunch at 1pm

Comes home by 5:30pm

Studies for 1-2 hours

Has dinner at 9pm

Goes to bed at 10 pm

This routine has changed due to her health issues

Personal History -

She consumes mixed diet with normal appetite

She has adequate sleep

Her bowel and bladder movements are regular

She has no Allergies and Addictions.

General Examination :

Patient is conscious, coherent, cooperative.

Temperature - 98.6°F

Pulse - 86 beats/min

BP - 100/60 mmHg

RR - 18 cycles/min

GRBS - 107 mg/dl

SPO2 - 98 %

 Pallor present 

No Icterus ,Clubbing ,Cyanosis, Lymphadenopathy

SYSTEMIC EXAMINATION :

CVS :

S1,S2 heard

No thrills ,murmurs

RESPIRATORY SYSTEM :

URT:

Nose: Left DNS present,No nasal polyps

Oral cavity : Normal oral hygeine

Posterior pharyngeal wall = Normal

LRT:

INSPECTION:

Shape of chest : Elliptical, B/L Symmetrical

Trachea : Appears to be central

Chest movements : equal on both sides 

Apical Impulse : not seen 

No supraclavicular and infraclavicular hollowness

No crowding of ribs , drooping of shoulders , Wasting of muscles.

No usage of accessory muscles of respiration 

No Kyphosis, Scoliosis , Sinuses , Scars , Engorged Veins and visible pulsations.

PALPATION:

No local rise of temperature

No tenderness

All inspectory findings are confirmed

Trachea : central

Chest movements : equal on both sides

Apex beat : Felt at 5th ICS medical to MCL

TVF : Increase in Rt ISA, Infra SA,IAA

AP diameter -20 cm

Traverse - 25cm

Right Hemithorax - 37cm

Left thorax - 36 cm

Chest circumference -

Inspiration - 75cm

Expiration - 73cm

Chest expansion - 2cm

Vocal fremitus equal on both sides in all areas

PERCUSSION -

Resonant in all areas on both sides

AUSCULTATION -

BAE +ve

NVBS

Crepitus is heard in Right suprascapular, infrascapular, infraclavicular and left infraclavicular, infrascapular.

Vocal resonance same on both sides

ABDOMEN :

Shape - Scaphoid

No tenderness, palpable mass, No Fluid

No bruits 

Liver not palpable

Spleen not palpable

No Bowel sounds 

CNS Examination

Pt is Conscious ,coherent, cooperative

Speech normal

Cranial nerves, motor system, sensory system Normal

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Bronchiectasis

TREATMENT :

 Inj PIPTAZ 4.5gm IV TID

Inj PAN 40 mg IV OD BBF

Syp ASCORIL 2tsp TID

Neb with Ipravent 6th hourly

- Budecort 8th hourly

Tab MUCINAC

Tab PCM High protein diet

IVF NS @75 ml/hr

Monitoring vitals 

Chest physiotherapy