General medicine

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 a diagnosis and treatment plan.

CHIEF COMPLAINT:
A 45 year old female came to causality with a chief complaint of cough with sputum since 7days and shortness of breath since 7 days.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back then she developed cough with sputum which aggrevated from 7 days. Sputum is mucoid, non blood stained , non foul smelling.
Seasonal variation-cough is more during nights
aggrevated on exposure to dust and cool air .
Then she developed breathlessness from 7 days which is of grade-ll, gradual in onset, seasonal variation on exposure to dust and cool air. 
Wheeze- present 
No orthopnea, no paroxysmal nocturnal dyspnoea , no cause of fever, chest tightness , palpitations,hemoptysis and sweating 
Throat pain ,burning micturition and History of allergy. 

HISTORY OF PAST ILLNESS:
No h/o  loss of weight or loss of appetite 
No similar complaints in the past
Known case of Hypothyroidism since 5 months (Thyronorm 50mcg)
No h/o Diabetes mellitus, Hypertension,Coronary artery disease , Epilepsy, Tuberculosis.


PERSONAL HISTORY: 
Appetite : Normal 
Diet: Mixed 
Bowel and bladder movements: Regular 
Addictions : No 
Micturition: Burning micturition
Known Allergies : yes to dust and cool air 

FAMILY HISTORY: 
Not significant 

Menstrual History: 
Age of menarche-12 years 
Duration-3 to 5 days , normal flow for every 28days 

General Examination: 
The patient is conscious, coherent and cooperative and well oriented to time, place and person
Moderately built and well nourished 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and Edema 

Vitals:
Temperature: Afebrile 
Pulse rate: 95/min
Respiratory rate: 22/min 
BP: 120/80mm /Hg
Spo2 at room air 97% 
GRBS:132mg% 

Systemic examination: 
Upper respiratory tract examination:
Left sided deviated nasal septum 
Oral cavity- normal oral hygiene 
Lower respiratory tract :
Inspection :
- shape of chest is symmetrical,elliptical 
- Chest expansion equal on both sides 


Palpation :

All inspectory findings are confirmed with palpation.
 Trachea central in position.
  Apex beat felt at Left 5th intercoastal space, 1 inch median to mid clavicular line
 No local rise in temperature
 No tenderness 
 Chest movements: Equal on both sides
          
Auscultation: 
Bilateral air entry present 
Vesicular breath sounds
No added sounds 

  Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No
 
clinical images:

INVESTIGATION:
chest x-ray:









Provisional Diagnosis:
Bronchial Asthama 

Treatment: 

Tab.Azec 500mg OD
Tab.Monter Levo 80mg OD
Syp. Ascoryl 2tsp BD
Tab pantop 40mg OD
Tab paracetamol 650mg if temperature >99•F

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