68YEAR OLD FEMALE WITH SHORTNESS OF BREATH

SUDHAMSHI REDDY M

This is 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 patients 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 on comment box is welcome .

 

I’ve 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 . 

COMPLAINTS AND DURATION:

-Patient c/o cough since 6 months

-Shortness of breath since 4-5 months 

HISTORY OF PRESENTING ILLNESS:

-Patient was apparently normal until 6months back,then she developed 

-Productive cough, insidious in onset, gradually progressive with white colored mucoid sputum, relieved on taking medication and aggravated mostly at night time around 3-4AM
-Shortness of breath: since 4-5 months, insidious in onset and gradually progressed to grade-IV now. 

  Increases on walking few steps.
-Orthopnoea present, feels better on lying to lateral side, patient also gives h/o PND

H/o decreased appetite since 4 months
No H/O fever, burning micturition, pain abdomen, chest pain, palpitations, decreased urine output, pedal edema.

.

PAST HISTORY:

-H/o decreased appetite since 4 months.

-No h/o fever/ burning micturition/ pain abdomen / chest pain/ palpitations.

No Decreased urine output/ pedal edema.

-Not a k/c/o DM/HTN/TB/ Epilepsy / CVA / CAD/ thyroid diseases

- H/o fall 2 years back -  Right ankle  # - POP applied.

PERSONAL HISTORY:

-Normal appetite, mixed diet with regular bowel and  

  bladder habits 

-Addiction of smoking : 

  2-3beedis/day started 8years back ,stopped 2 years  

  back.

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR: PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, PEDAL EDEMA, LYMPHADENOPATHY.

VITALS ON ADMISSION:

PR-96BPM

BP- 120/70MM HG

RR- 20CPM

SPO2- 99% AT RA

SYSTEMIC EXAMINATION: 

CVS:

S1 S2 PRESENT

NO THRILLS AND NO MURMURS

RESPIRATORY SYSTEM:

INSPECTION:

CHEST IS BILATERALLY SYMMETRICAL

TRACHEA MIDLINE IN POSITION

APICAL IMPULSE NOT APPRECIATED

CHEST IS MOVING NORMALLY WITH RESPIRATON NO DIALTED VEINS, SCARS, SINUSES.

PALPATION:

TRACHEA MIDLINE IN POSITION

APICAL IMPULSE FELT ON 5TH INTERCOASTAL SPACE

CHEST IS MOVING EQUALLY WITH RESPIRATION ON BOTH SIDES.

PERCUSSION:

ON PERCUSSION RESONANT NOTE HEARD.

AUSCULTATION:

NORMAL VESICULAR BREATH SOUNDS HEARD NO ADVENTITIOUS SOUNDS HEARD.

ABDOMEN:

SHAPE OF ABDOMEN: SCAPHOID NO TENDERNESS

NO PALPABLE MASSES

NO FREE FLUID AND NO BRUITS LIVER IS NOT PALPABLE

SPLEEN NOT PALPABLE

BOWEL SOUNDS:PRESENT

CNS:

HIGHER MENTAL FUNCTIONS- INTACT

MEMORY- ABLE TO RECOGNISE HIS FAMILY MEMBERS AND RECALL RECENT EVENTS SPEECH: NORMAL

CRANIAL NERVE EXAMINATION- NORMAL REFLEXES-

                      RIGHT          LEFT

BICEPS            2+                 2+

TRICEPS          2+                 2+

SUPINATOR     1+                1+ 

KNEE                2+                2+

ANKLE.            2+                 2+

SUPERFICIAL AND DEEP REFLEXES ARE PRESENT AND NORMAL

MUSCLE POWER- 

                                    RIGHT           LEFT 

UPPER LIMB  

ELBOW                         5/5                  5/5 

WRIST                           5/5                  5/5 

HAND GRIP                  5/5                  5/5

LOWER LIMB 

HIP                                   5/5                 5/5 

KNEE.                              5/5                 5/5 

ANKLE                            5/5                 5/5

TONE- NORMAL IN UPPER AND LOWER LIMBS

NO INVOLUNTARY MOVEMENTS

SENSORY SYSTEM- ALL SENSATIONS ARE NORMAL

INVESTIGATIONS:

Hb- 10.7gm/do

TLC-7900cells/cu.mm

PLT-2.04lakhs/cu.mm

Creatinine- 0.8mg/dl 

Urea- 22mg/dl

RBS- 101mg/dl

LFT

TB- 0.76mg/dl

DB- 0.20mg/dl

AST-19IU/L

ALT-16IU/L

ALP- 142 IU/L

TP- 6.7gm/dl

ALB- 3.3gm/dl

Na- 141

K- 3.6

Cl- 99

Ca- 0.9

Serology- negative

ECG

CHEST X-RAY

SPUTUM CULTURE AND SENSITIVITY: Normal oropharyngeal flora grown.

2D ECHO -

IMPRESSION: TRIVIAL TR+/AR+, NO MR

NO RWMA, NO AS/MS

GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION

NO PAH/PE

SPUTUM CBNAAT - NEGATIVE.

DIAGNOSIS:

ACUTE EXACERBATION OF COPD.

COURSE IN THE HOSPITAL:

PATIENT CAME WITH THE ABOVE MENTIONED COMPLAINTS- PRODUCTIVE COUGH AND SHORTNESS OF BREATH SINCE 5 TO 6MONTHS. THOROUGH CLINICAL EXAMINATION AND INVESTIGATIONS WERE DONE. ON RESPIRATORY EXAMINATION BILATERAL AIR ENTRY WAS EQUAL, NO ADDED SOUNDS WERE HEARD. CHEST XRAY SHOWED NO ABNORMALITIES.

GRAM STAIN,ZN STAIN AND CBNAAT OF SPUTUM SAMPLE TURNED OUT TO BE NEGITIV AND CULTURES SHOWED GROWTH OF NORMAL ORAL MUCOSA.

ACCORDING TO THE ABOVE FINDINGS PULMONARY KOCHS WAS RULED OUT AND WAS SUSPECTED WAS CHRONIC OBSTRUCTIVE PULMONARY DISEASE. SYMPTOMATIC TREATMENT WAS GIVEN WITH NEBULISATION WITH SALBUTOMOL AND BUDECORT DURING THE STAY IN THE HOSPITAL AND PATIENTS SYMPTOMS IMPROVED GRADUALLY. PRODUCTIVE COUGH AND SHORTNESS OF BREATH HAVE DECREASED.

PATIENT IS BEING DISCHARGED ON INHALERS DUOLIN4TH HOURLY AND BUDECORT 12TH HOURLY

TREATMENT: 

1. SYRUP ASCORYL 2 TSP TID X 12DAYS

2. TAB LEVOCETRIZINE 5MG PO BD X 12 DAYS

3. TAB PAN 40MG PO OD X 12 DAYS

4. NEBULISATION WITH DUOLIN 4TH HOURLY , BUDECORT 12TH HOURLY. X 12 DAYS

 5. SYP. CREMAFFIN 10ML PO HS X 9DAYS

ADVICE AT DISCHARGE: 

1. SYRUP ASCORYL 2 TSP TID

2. TAB LEVOCETRIZINE 5MG PO BD

3. TAB PAN 40MG PO OD

4. INHALERS WITH DUOLIN 4TH HOURLY , BUDECORT 12TH HOURLY.

5. SYP. CREMAFFIN 10ML PO HS