62F SOB 1YR HEADACHE 1 MONTH

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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.

60 Year old female came to opd with  chief complaints of 

Headache  1 month.

Cough since 5 days.

HOPI:

Pt is apparently asymptomatic

until one year ago then she developed SOB Since 1 year Grade 1,No orthopnea,No Pnd,no chest pain,Since 1 month she developed Headache ,diffuse type radating to neck.

Clo Fever ago - High grade,associated with chill and Rigor; Intermittent; No diurnal  Variations.

C/o Cough since 5 days.productive cough,white in colour.

No Clo Sweating,Palpitations ,

loose stools,Nausea; Vomiting,Burning Micturition.

PAST HISTORY:

N/K/CIO DM,Hypertension,Epilesy, Asthma, Thyroid disorders.

PERSONAL HISTORY:

DIET :mixed

APPETITE : Normal

SLEEP: adequate 

BOWEL AND BLADDER :Regular 

No addictions 

FAMILY HISTORY: 

N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders.

GENERAL EXAMINATION:

Patient is conscious,coherent and co operative.

Well oriented to time,place and person

No Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema.

VITALS:

TEMP: 97.2 F

BP: 130/80 MM/HG

PR: 88 BPM

SPO2: 98% at RA

RR: 20CPM

SYSTEMIC EXAMINATION:

RS:

Position of trachea :central 

Vesicular breath sounds present .

Wheeze present in Bilateral  Suprascapular , Infrascapular, Mammary areas .

CVS : S1 , S2 heard, no murmurs 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits

S:No fever spike present 

Cough productive present.

SOB present.

Investigations:

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp:97.6F 

PR:90BPM

BP:130/80 MM/HG

GRBS:136mg/dl

RR:21CPM

RS:B/L AE present ,Wheeze present in B/L suprascapular , Infrascapular, mammary area

CVS: S1 ,S2 heard

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

Haemoglobin:10.1 g%

RBC: 4.3million/mm3

Platelet count:2.2lakhs/mm3

TLC:12,600 cells /mm3

A:Pyrexia secondary to  Lower Respiratory tract infection,H/o Bronchial Asthma(Exacerbation)

P:

1)IV FLUIDS NS @75ml/hr

2)Inj Amoxicoav 1.25 gm/IV/ TID

3)Tab Azithromycin 500 mg / po/ od

4) Nebulization with Duolin 8 th hourly,Budecort 12 th hourly 

5)Inj Hydrocort 100 mg /IV/Stat

 6)Inj. Neomol 1 gm  IV/SOS

7)Monitor vitals