15 years old school student with 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.

Long case 

Stimita Maity 

H.tno 1701006178

Chief complaints 

A 15 years old male presented  with the complaints of chest pain and heaviness in the left side of the chest since 3 months. 

History of present illness 

Patient was apparently asymptomatic 3 months ago,then he developed pain and heaviness in the left side of the chest.

** Pain was insidious in onset, gradually progressive, squeezing type,non radiating, aggravated on exercise and relieved on taking rest.

For chest pain he was given Pantoprazole for 10 days but didn't get subsided.

** Heaviness in the chest increased on lying on the left side.

** h/o evening rise of temperature ( around 4:30)

** h/o easy fatiguability

** No h/o  cough, haemoptysis, breathlessness, wheezing

Past history 

** 4 years ago he developed generalised body and joint pain and was managed in a govt hospital by paracetamol. 

**  2 years  ago he developed pain in the left side of face and was diagnosed with herpes managed medically

**  not a known case of Hypertension, diabetes,epilepsy, TB,Asthma

** no h/o any direct trauma or surgery in the chest 

Birth history 

Normal vaginal delivery at term

Cried soon after birth 

No TORCH infection after birth or in mother during pregnancy 

Colostrum fed

He was breastfed only for 1 month as he developed chronic diarrhoea at the age of 9 days so local doctor said to stop breastfeeding and also was managed by some injection. 

So from the age of 1 month he was fed outside milk,barley.

Immunized. 

Personal history 

Takes mixed diet( does not eat vegetables ,consumes less water)

Gets adequate sleep 

Appetite normal

Bladder movement regular 

H/o constipation 

No addiction 

H/o dust allergy 

Family history 

No h/o Tb in family members 

Grand father and grandmother have asthma

Mother has dust allergy 

Treatment history 

Treatment for chronic diarrhoea at 1 month of age

Treatment for generalised body pain 4 yrs ago

Treatment herpes 2 yrs ago

Examination 

General examination 

Well informed consent was taken. Patient was examined in a well lit room.

Patient was conscious, coherent and cooperative, well oriented to time,place and person. Moderately built and moderately Nourished.

There is no pallor,icterus,clubbing, cyanosis,pedal edema  lympathadenopathy. 

Vitals 

Afebrile 

BP 110/70 mm of hg

PR 72bpm

RR 18cpm

Respiratory system examination 

Inspection

examination of oral cavity : normal 

            Nose normal 

   

   Shape of chest elliptical 

Expansion of chest  symmetrical 

Trachea: central in position 

Apical impulses :  not visualised

 no drooping shoulder 

No crowding of ribs

No supra or infraclavicular fullness or hollowness

No sinus,scar

No kyphoscoliosis

Palpation 

Inspectory findings are confirmed. 

Trachea : central 

No local rise of temperature 

No tenderness 

Expansion of chest symmetrical 

Tactile vocal fremitus :  felt,decreased on left  side in infraaxillary and infrascapular region 

Apex beat at 5th intercostal space medial to midclavicular line.

Percussion 

Direct on clavicle : resonant

Supraclavicular,infraclavicular,mammary,inframammary,suprascapular,interscapular,axillary : resonant

Infraaxillary and infrascapular : dull note

Shifting dullness  present 

Auscultation

Bilateral air entry present 

 vesicular breath sound  heard

Decreased intensity of breath sound at left infraaxillary and infrascapular area.

No added sound 

Respiratory system examination 

Chest expansion 

 

Abdominal examination 

INSPECTION:

•Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

 PALPATION:

•No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

 PERCUSSION:

•There is no fluid thrill , shifting dullness.

Percussion over abdomen- 

tympanic note heard.

 AUSCULTATION:

 Bowel sounds are heard.

Cardiovascular system examination 

INSPECTION:

Chest wall - bilaterally symmetrical 

No dilated veins, scars, sinuses

PALPATION:

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

No parasternal heave, thrills felt

 AUSCULTATION:

•S1 and S2 heard , no added thrills and murmurs heard.

Central nervous system examination

CENTRAL NERVOUS SYSTEM EXAMINATION.

 HIGHER MENTAL FUNCTIONS:

•Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system: Intact

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

•Sensory system - 

-All sensations pain, touch,temperature, position, vibration, are well appreciated.

Investigations

CBP : HB 13.2gm%

Tc 6300

N 52%

L 37%

E 2%

M 9%

B 0

Serology negative 

 Chest x ray

CT scan

Bacterial culture 

Bronchoscopy

USG

Provisional diagnosis 

Left sided hydropneumothorax

Treatment 

O2 inhalation with nasal prongs with 2 ltrs /mint

Nebulization with duolin

Tab dolo 650mg sos 

Advice at discharge::  paracetamol If temp above 99F

Avoid strenuous exercise