A 54 ur old male presents with SOB, abdominal tightness and rib fracture

August 1 2023,

Hello, Mr name is Neha Rama and I am a 5the semester medical student studying in Kaminenei Institute of Medical Sciences, Narketpally. This is an online blog  discussing patient health data after taking his/her consent. This also reflects my patient centered online learning portfolio. 


Case sheet 

A 54 year old patient who is a resident of suryapet and a daily laborer by profession came to the OPD with chief complaints of Shortness in breath since 3 months, abdominal tightness since 2 months and a traumatic injury to the left upper side of the abdomen since 3 days. 


History of present likeness 

The patient was apparently asymptomatic 3 months ago after which he developed SOB grade 1. It was gradual in onset and aggravates on walking,on supine position and decreases when he sleeps in lateral positionposition(both right and left).

Continuous,non progressive.


It is not associated with chest pain.

No h/o cough,sweating, palpitations.

He started experiencing abdominal tightness 2 months ago which aggregated after food intake and was relieved on medication. He suffered from trauma to the left rib 3 days ago while doing labor work. 


History of past illness 

No h/o Diabetes/HTN/TB/ asthma/ epilepsy/ CVS disorders.

H/o trauma to the left rib 3 days ago.


Family history 

No family history of HT/diabetes/ TB/Heart diseases/Cancer/asthma.


Surgical History

Never underwent any surgeries 



PHYSICAL EXAMINATION 


GENERAL EXAMINATION

Well built

Well nourished

No pallor


IMG_5831.jpeg


No icteris 

No clubbing of fingers 

IMG_5833.jpeg


No cyanosis 

IMG_5834.jpeg


No pedal oedema

No lymphadenopathy

Mild dehydration


VITALS 

Temperature - 99°F

Pulse - 92 bpm

Respiratory rate - 16 rpm

BP -120/80 


SYSTEEMIC EXAMINATION 


Respiratory system examination 


INSPECTION:


•Chest is bilaterally symmetrical

Trachea – midline in position.0

Apical Impulse is not appreciated 

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.



PALPATION:


•Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 


 

PERCUSSION:


The following areas were percussed on either sides- 


Supraclavicular-resonant

Infraclavicular- resonant

Mammary- resonant

Axillary- resonant

Infraaxillary- resonant

Suprascapular- resonant 

Infrascapular- resonant 

 interscapular - resonant.


 

AUSCULTATION:


•Normal vesicular breath sounds heard.


Abdominal examination 


Distended

IMG_5840.jpeg



IMG_5839.jpeg



Abdominal rigidity present


No fluid  thrill


No shifting  dullness 




CVS examination 



S1,S2 heard, no murmurs 

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