A 24 year old female came to the opd with the c/o of pain in the right side of chest , associated with swelling since 3-4 days.
GENERAL MEDICINE
~Case based discussion
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient - centered online learning portfolio and your valuable inputs in the comment box .
I have been given this case to solve in an attempt to understand the patient clinical data analysis to develop the competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 24 year old female came to the opd with the c/o of pain in the right side of chest , associated with swelling since 3-4 days.
Apparently the patient was asymptomatic 4 days ago later she developed a sudden pain in chest and right hypochondriac region, radiating to lumbar region. It was gradual in progression , dragging type of pain and aggravated on sleeping on right side, relieved on rest.
The pain was associated with swelling which she noticed 4 days back which was small and nodule like sudden in onset and gradual in progression which progressed to about 5 cms extending like a long linear line reaching the lumbar region.
No history of local rise in temperature, no h/o fever, headache, vomiting, weight loss, loss of consciousness, shortness of breath, joint restriction, pain on inspiration/expiration
No known comorbidities.
Past history: No similar complaints in the past and nothing of significance
Personal History:
Normal appetite
Adequate sleep
Regular bowel bladder movements
No addictions
On examination -
General Examination:
The patient is moderately built, conscious, cooperative , coherent and well aware of surrounding place and time. Consumes mixed diet.
No pallor, icterus, cyanosis, clubbing and generalized lymphadenopathy.
Vitals : BP : 120/ 80 mm of Hg
Pulse : 74 beats per min
Temperature : afebrile
Respiratory rate : 16 cpm
Systemic examination:
Chest and abdomen region:
longitudinal linear swelling, no local rise in temperature,
Tenderness+
Slip test -ve
Size : about 5cms
Axillary lymph nodes : Normal
Breast examination: Normal
Ultrasound: Normal
Treatment: NSAIDS
Comments
Post a Comment