General Medicine E-log (4)


A 17 YEAR OLD MAKE CAME WITH FEVER AND SHORTNESS OF BREATH.

Hi, I am Danush Varkur, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:

A 17 old male student, came with chief complaints of:
- fever since 7 days
- shortness of breath since 5 days
- right side chest pain since 3 days increased on inspiration.

History of present illness:

The patient was apparently asymptomatic 7 days back. He then developed high grade fever which was associated with chills and rigors. Fever was not relieved on medication.

He the developed breathlessness 5 days back, which was insidious in onset, mMRC grade 2, which was aggrevated on lying down, with no seasonal variation.

He also complained of right sided chest pain since 3 days, which was non radiating.

No complaints of chest tightness, palpitations on cough.

Past history:

- Not a known case of Diabetes mellitus, hypertension, epilepsy 

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema

VITALS:

Temperature: 102.5 F

Pulse:102 beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 120/80 mm of Hg

SPO2: 99%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 heard

Respiratory system:

dyspnea is present
No wheezing
Breath sounds heard: vesicular

Abdomen:

No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal
  
INVESTIGATIONS:
USG:
ECG:
Provisional Diagnosis:
Right side mild pleural effusion

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