THIS IS AN ONLINE E-LOG TO DISCUSS DE-IDENTIFIED HEALTH DATA OF OUR PATIENTS.
CASE PRESENTATION
CHIEF COMPLAINTS:
- Difficulty in breathing
- Cough for 15 days
HISTORY OF PRESENT ILLNESS:
- Patient was apparently asymptomatic for 15 days
- He then developed Shortness of Breath of Grade 2,
which had no aggravating or relieving factors & was sudden in onset.
- No positional & Diurnal variation
- History of weight loss (8 Kgs in 6 months)
- Loss of appetite for 15 days
- No history of cold or fever
HISTORY OF PAST ILLNESS AND TREATMENT:
-K/C/O of Cerebrovascular accident 2 years back
(Not on medication for 3 months)
-K/C/O COPD 2 years back
(Used Formonide 400 mg with Spacer: used for 15 days & discontinued)
-N/K/C/O Hypertension, Diabetes Mellitus, Epilepsy, Asthma, Tuberculosis
PERSONAL HISTORY:
- Appetite: Lost
- Diet: Mixed
- Bowel & Bladder Movements: Normal
- Allergies: None
- Habits: Alcohol (Daily 90 ml for 40 years) Now just occasional
Smoking for 40 years (32 BD/Day)
FAMILY HISTORY: insignificant
GENERAL EXAMINATION:
-Pallor: Absent
-Cyanosis: Absent
-Clubbing: Absent
-Lymphadenopathy: Absent
-Pedal Edema: Absent
-Vitals:
Blood Pressure: 110/80 mmHg
Pulse Rate: 86 bpm
Respiratory: 16CPM
Temperature: Afebrile
SPo2%: 98%
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1S2+
No murmurs present
RESPIRATORY SYSTEM:
Wheeze +
Dyspnoea + (Grade 2)
Inspection:
Size and shape of chest: Barrel-shaped
Movement of chest: Respiratory rate- 18cpm Rhythm-Normal Type- Abdominothoracic
Expansion: Bilaterally symmetrical
Position of Trachea: Central
Palpation:
No local rise in temperature, No tenderness
Movement of chest:
Right Left
Supraclavicular: Symmetrical Symmetrical
Mammary: Symmetrical Symmetrical
Inframammary: Symmetrical Symmetrical
Axillary: Symmetrical Symmetrical
Infra Axillary: Symmetrical Symmetrical
Suprascapular: Symmetrical Symmetrical
Scapular: Symmetrical Symmetrical
Infrascapular: Symmetrical Symmetrical
PER ABDOMINAL EXAMINATION:
No abnormalities detected
CENTRAL NERVOUS SYSTEM:
No focal neurological deficit
INVESTIGATION:
DIAGNOSIS:
Acute Exacerbation of Chronic Obstructive Pulmonary Disease
(Emphymatous)
K/C/O Cerebrovascular Accident (2 years)
TREATMENT:
TAB. ECOSPIRIN - AV 75/10 PO/ OD /HS
SYP. GRILLINCTUS 10 ML PO/ TOD
NEB. WITH DUOLIN- 8th HOURLY & BUDECORT- 8th HOURLY
TAB. MONTAER LC-PO/HS
TAB. PULMOCLEAR PO/BD
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