A 35 year old female came with the chief complaints of breathlessness since 8 days
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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. is an 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.
CASE
A 35 year old female,resident of miryalguda,worker in steel shop,came with chief complaints of shortness of breathe since 8days
HOPI :She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigor,for which she went near local RMP and took injections and temperature decreased.
And then she developed breathlessness 8 days back,which was insidious in onset.SOB is of grade 2 and history of orthopnea is present.SOB aggrevated on exposure to dust and cool air,seasonal variation is present.
History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggrevated on lying in supine position and relieved gradually on sleeping to one side.
History of chest pain since 8days,which is dull aching type,radiating from left lower costal margin upward to back.No h/o tightness in chest, palpitations.
No h/o burning micturition,loss of weight.
PAST HISTORY:
Similar complaints 1 week back for which she went to local hospital in miryalguda,where investigations like chest x-ray and CT scan is done,showing large consolidations and ground glass opacities seen in the superior and posterior basal segment of left lower lobe of lung and small ground glass opacities seen in posterior basal segment of right lower lobe of lung.Suggesting of acute pulmonary infection(?viral pneumonia)
She is a known case of Asthma since 6years, which was aggrevated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.
She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.
She is not a known case of DM,HTN,TB,Epilepsy,CAD.
She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.
PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal and food taboos present for Brinjal as she belives that consumption may aggravate SOB.
Sleep: decreased since 8days d/t chest pain.
Bowel,bladder:regular movements.
No addictions.
FAMILY HISTORY :No significant family history.
Not allergic to any drugs.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,edema appears on long standing and decreases on taking rest.
Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.
SYSTEMIC EXAMINATION:
PER ABDOMEN:Soft,non tender and organomegaly
CNS:No focal neurological deficits.
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Chest movements equal on both sides.Spinoscapular distance equal in both sides.
No accessory respiratory muscles are used in respiration.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Trachea appears to be central.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.
AP Diameter-30cms
Transverse diameter-34cms
Circumference-inspiratory-113cms, expiratory-110cms
Right hemithorax- 55cms
Left hemithorax-56cms
Percussion:
On direct percussion resonant note is heard
On indirect percussion:impaired note in left ISA,IAA
Auscultation:
Bilateral air entry present.
Decreased breathe sounds in left ISA,IAA.
Cvs examination : s1 and s2 heard no murmurs heard.
Investigations:
On 26/12/2022,
Her ESR levels were 170mm in first hour
Neutrophilic count:81%
LFT:
Serum total bilirubin:1.1mg/dl
Serum direct bilirubin:0.4mg/dl
C-reactive protein:61.7mg/l
Chest x ray:
On 28/12/2022,
This is taken from local hospital in miryalguda.
On 03/01/2023,
This x-ray is taken in our hospital.
Treatment:
On 03/01/2022,
Inj.CEFTRIAXONE-1gm,iv,bd
Inj.PAN-40gm,iv,od.
Inj.NEOMOL-100ml,iv if temperature>101
Tab.PARACETAMOL-650m,po,tid
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od
On 04/01/23,
Investigations:
Inj.CEFTRIAXONE-1gm,iv,bd
Inj.PAN-40gm,iv,od.
Inj.NEOMOL-100ml,iv if temperature>101
Tab.PARACETAMOL-650m,po,tid
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od
Inj.LEVOFLOXACIN-750 mg,iv,od.
FOLLOW UP ON 5/1/2023
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