69/F with shortness of Breath

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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.

A 69 years old female patient farmer by occupation came to casuality with chief complaints of SHORTNESS OF BREATH since 10 days

Decreased appetite since 4days

History of presenting illness::

Patient was apparently asymptomatic 5 years back then she developed Shortness of breath and was taken to private hospital was treated with Nebulization , Diagnosed as Bronchial Asthma and was on medication since then.

Shortness of breath seasonal variation ( every year during winters)

Patient developed similar complaints with fever and was admitted in Private hospital was treated as Bronchial asthma 6 months back

10days back she developed Shortness of breath grade MMRC grade 3 which was   insidious in onset  and gradually gradually progressive. Complaint of cough non productive, fever.

Not associated with chestpain , Palpitations, sweating

No history of orthopnea , paroxysmal nocturnal dyspnea.

Symptoms were relived in giving medication Nebulization

4 days back  patient developed increased shortness of breath MMRC grade 4 , weakness , increased fatigue,  decreased appetite, unable to move from bed or walk without support 

Yesterday patient was taken to miryalaguda hospital with Complaint of shortness of breath and unable to swallow more for solids .

Evaluation was done and referred to our hospital 

Past History:

10 years back patient had history of fall (head injury) which was not associated with loss of consciousness, projectile vomiting , seizure, weakness of limbs

Nueroimaging  of brain was done

She was  diagnosed with Hypertension and was started on medication.

Patient was diagnosed with hypothyroidism

since 4 years

Not a known case of DM, Tuberculosis ,epilepsy

Family History

Not significant

Personal History

Diet Vegetarian

Appetite Decreased

Sleep adequate

Bowel and bladder movements regular

No addictions and allergies to pollen dust

Daily routine:

She wakes up in morning

Eats 3 times

Walks around the house or sleeps

General Examination 

Patient is conscious, coherent and cooperative

Well oriented to time place and person

Pallor -present

No Icterus, Clubbing, cyanosis,lymhadenopathy, pedal edema

Thin built and malnourshed

Vitals:

RR 27cpm

BP 110/70 mm Hg

PR 120bpm irregular

SpO2 89%on Room air and 96% on 2litres of O2

GRBS 141mg/dl

SYSTEMIC EXAMINATION:

RESPIRATORY SYSYTEM

Inspection

Shape of chest elliptical 

Bilateral chest symmetrical

Equal chest expansion on both sides

Thoracoabdominal type

Trachea  appears to be central

Supraclavicular hollow present

No muscle retraction, grunting, crowding of ribs

Palpation-:

All inspectory findings confirmed

No rise of temperature

No tenderness

Chest circumference 72 cm

Anterior posterior 20 cm

Transverse  32 cm 

Ratio is 0.625 (5:8) (Normal is 5:7)

Trachea central

Symmetrical chest movements

Apex beat left 5th intercoastal space

Percussion-:

Resonant in all areas

Resonant in Right 6th Intercoastal space Tidal percussion

Auscultation-:

Bilateral air entry present

Crepitations at bilateral infra axillary area

Rhonchi at infra axillary and infra scapular area 

CNS Examination

No focal nuerological deficiet. 

CVS- :

S1 S2 heard, no murmur

P/A - 

Soft, non Tender, no organomegaly

INVESTIGATIONS:

##COMPLETE BLOOD PICTURE::

##LIPID PROFILE

##SERUM ELECTROLYTES

##ECG:

##SERUM CREATININE:

##BLOOD UREA::

##ABG

##Urinary electrolytes:

X RAY:

##2D ECHO:

##LFT:

 PROVISOINAL DAIGNOSIS

Asthama? 

COPD ?

Miliary TB? 

With Hyponatremia, hypokalemia