15 year old boy with chest pain and dyspnea

May 30, 2022

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

PAST HISTORY: Pt is a 15-year-old boy, studying in class 10. At the age of 8 - 9 yrs, he used to have nonspontaneous whole body/jt. pain and aches (2 - 3 episodes every day), pain in the lower back, sometimes accompanied by fever; for which he got treated by a Clinician (recommended Ibuprofen syrup), and the problem was resolved. At the age of 9 - 10 years while learning how to ride a bicycle he was involved in an accident which resulted in the fracture of his rt. humerus. Had to use an arm sling pouch and it healed within 2 - 3 months. He recalled that after the accident he was senseless for almost an hour and got a heavy blow to his chest during the incident. At the age of 11 - 12 years, he got infected with HSV, resulting in painful red blisters on his left cheek; with fever. It got resolved within a month with medication. But, he noticed that after that his left eye appears to be a little smaller than the rt eye. At the age of 13 - 14 yrs, while playing football he fractured his left wrist. Cast immobilization lead to full recovery. He says he does not feel like eating much ever since childhood, has digestion problem.

PRESENT HISTORY: For the past 1 - 1.5 months feeling a sharp, stabbing pain in the extreme left side of the lung which increases during inhalation. While riding a car, due to jerking he can feel as if some fluid is vibrating in his chest. Complaint of persistent dry cough whole day. In the morning, after walking up he feels breathless. In the evening there is a slight fever (99 - 100). Diagnosed with pneumothorax. Currently, under medication (Lupituss Syrus, tab. Myospaz, Aceloc rd, Moxclab 625mg for 5 days) for the same but reports that the pain has not resolved. He is complaining of abdominal pain for the last 1.5 month. And his stool frequency is once in 2 days for the last 4-5 months. Stool is of solid consistency.