Long case 1 (1/12/2023)
November 29, 2023
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
A 60 year old female has come to the opd with
CHIEF COMPLAINTS of
1. shortness of breath since 2 months
2. Chest pain 10 days back
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2months back when she developed shortness of breath which was insidious in onset aggravating on cold exposure and relieving when taking rest
20 days back the symptoms were exaggerated and patient was unable to go to the washroom without having to stop to catch her breath
10 days ago patient experienced chest pain localised to precordium which was sudden in onset, severe and stabbing type and lasted till she reached the hospital
Dry cough is also present since 7 days, aggravating in the night and relieving on medication
H/O orthopnea
No H/O paroxysmal nocturnal dyspnea
No H/O fever, chest pain, chest tightness, hemoptysis, sweating, palpitations
No H/O weight loss
PAST HISTORY
Similar complaints 10 years ago. Usage of rotahaler (Fluticasone + vilantrol)
Patient on Tab. Acebrophyllin 100mg PO/BD.
Patient on Diabetic medication.
No H/O TB, epilepsy, thyroid disorders, HTN, in the past.
FAMILY HISTORY
Elder sister K/C/O Asthma since early childhood
PERSONAL HISTORY
Diet - Mixed
Appetite - Normal
Sleep- Adequate
Bowel and bladder movements- Normal
Addictions - None
TREATMENT HISTORY
Inhaler usage since 10 years for asthma.
No H/O blood transfusions or surgeries.
GENERAL PHYSICAL EXAMINATION
Patient is conscious, coherent and cooperative.
With moderate built and nourishment.
Pallor - present
Icterus - no
Cyanosis - no
Clubbing - no
Koilonychia - no
Lymphadenopathy - no
Oedema - Present
VITALS
Temperature - Afebrile
Pulse rate - 74 bpm
Respiratory rate - 16 cpm
BP - 100/60 mmHg
SpO2 - 96% at room temperature
GRBS - 350 mg/dL
SYSTEMIC EXAMINATION
1) Respiratory System
Inspection :
Shape of chest - barrel shaped
Position of trachea - central
Bilateral symmetrical chest expansion observed
Apical impulse ?
No visible pulsations/sinuses/scars seen
Palpation : (Confirming findings on inspection)
Trachea - central
Apex beat - normal
Respiratory movements - normal and equal on both sides
Vocal fremitus - normal
No tenderness over intercostal spaces
Percussion :
Resonant note heard bilaterally
Auscultation:
Vesicular breath sounds are heard.
CVS -
S1, S2 heard ;
JVP pressure normal
no murmurs or thrills heard.
ABDOMEN
Scaphoid abdomen, no tenderness, no palpable mass, normal hernial orifices, no free fluid, no bruits
No palpable spleen or liver
CNS -
All higher mental functions, cranial nerves, motor system and sensory system are intact.
Normal speech observed.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Acute exacerbation of chronic Asthma
TREATMENT
Salbutamol nebulisation
Ipratropium , budesonide nebulisation
Inj. Augmentin 1.2gm BD
Inj. Heparin 5000 IU QID
Inj. Lasix 40 mg BD
Inj. Pantop 40 mg BD
Tab ecosprin 75 mg OD
Tab. Clopidogrel 75 mg OD
Tab. Rosuvastatin 120 mg OD
Tab. Mucinac TID
Tab. Montac LC BD
Tab. Prednisolone 40 mg OD
Tab. Azithromycin 500 mg OD
Duolin budecort
The following is a reference throwing light on how obesity is related to incidence of asthma and increased frequency of exacerbations of asthma
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