A 15 yr old male patient with chest pain

Hall ticket no. 1701006119

Final practical exam- short case

A 15yr old male patient came with the complaints of:

-Chest pain since 3 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. First the parents thought it as acidity and took medication for it and not relieved.

For the first month pain is severe and took medication and next he didn't complain that much of pain and again in the last month ,pain started and got aggravated and they went to doctor.

They couldn't find any abnormality ,and they done investigations like Xray and couldn't find the abnormality.

No history of palpitations, PND, pedal edema, vomiting, hemoptysis, trauma.

Then he developed breathless since 1 month grade I(NYHA) Insidious in onset, gradually progression, aggrevated on lying down and on lying on left side. Relieved on sitting. 

Associated with dry cough 

Not associated with wheeze,cold

No history of fever, loose stools,sorethroat, headache.

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-  

Use of accessory muscles - not present 

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  

Provisional diagnosis:-

Mild left sided hydropneumothorax.

Investigations:-

Treatment:- conservative management-

Tab.paracetomol

IV fluids