68 year old female with breathlessness.

68 YEAR OLD FEMALE WITH BREATHLESSNESS.

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Date of admission -04-12-2022

This is a case of 68 years old female resident of nalgonda who has come to the casualty with the chief complaints of
Breathlessness and cough since 1 week.

HOPI:
Patient was apparently asymptomatic 1 week back then she developed breathlessness,which is insidious in onset and associated with wheeze and not associated palpitations and sweating.
H/o cough since 1 week.
No complaints of fever,chestpain, chest tightness, loss of weight, diarrhoea,vomitings.
she developed these symptoms due to change in weather.

Past history:
H/o similar complaints in the past,5 years back.
Used inhaler 2 years back for 1 month and then stopped.
Nebulization is taken since 1 week.
K/c/o HTN since 10 years.
N/k/c/o DM, epilepsy,CAD.
No past h/o TB
No h/o any previous surgeries.
No known allergies.

Personal history:
Diet- Vegetarian diet
Appetite- good
Bowel and bladder movements-Regular
Sleep- Adequate.
Habit- No addictions


Family history:
No significant family history.

General examination:
Patient is conscious, coherent, not so cooperative, well oriented to time ,place and person, well nourished and moderately built.

Pallor-absent
Icterus-absent
Clubbing-absent
Cyanosis-absent
Lymphadenopathy- absent
Edema- mild pedal edema

Vitals:
Temperature - afebrile 
Bloodpressure- 110/70mm of hg
Pulse rate- 98bpm
Respiratory rate- 21 cpm

Systemic examination.

Cardiovascular system.
S1 and S2 sounds are heard.

Respiratory system.
Inspection:
Shape of the chest- elliptical.
Symmetry - chest is bilaterally symmetrical.
Trachea appears to be in centre.
Expansion of chest is equal on both the sides.
No drooping of shoulders.



Palpation:
Trachea is in the centre ,no tracheal deviation is seen.
Expansion of chest is symmetrical on both the sides.

Percussion:
Resonant sounds are heard.
Apex beat Dull near the left 5th intercoastal space.

Auscultation:
Breath sounds are heard.
Vesicular heart sounds are heard.
Axillary heart sounds are heard.
Dull sound is heard near the left 5th intercoastal space.
Supraclavicular and infra clavicular ronchi sounds are heard.
Clavicular Crepts sounds are heard.
Axillary and infra axillary ronchi are heard.
Suprascapular and infrascapular crepts sounds are heard.

GIT examination
Abdominal examination
Shape of the abdomen is scaphoid
Soft and non tender
Bowel sounds are heard
No palpable mass

Centralnervous system examination:
No focal neurological deficets.

Provisional diagnosis:
Asthma
COPD

Investigations
Day- 1(4-12-2022)
CBP:
Blood sugar random
Blood urea
Serum creatinine 
LFT
ECG
CHEST X-RAY

Day-2( 5-12-2022)
SERUM ELECTROLYTES.
BLOOD UREA.
SERUM CREATININE.
HEMOGRAM.
LIPID PROFILE.
ABG.
ECG.

Day-3(06-12-2022).
ESR.
HEMOGRAM.
ABG.
BLOOD UREA.
SERUM CREATININE.
SERUM ELECTROLYTES.
ECG.
CHEST X-RAY.

Day-4(07-12-2022).
BLOOD UREA.
SERUM CREATININE.
SERUM ELECTROLYTES.
ECG.
CHEST X- RAY.
Day-5(08-12-2022).
CHEST X-RAY.
Final diagnosis:  COPD

Treatment:
                               
1. Inj. Hydrocortisone 100 mg IV BD
2.Inj. PAN 40 mg IV OD
3.Prednisolone 40mg
4. Tab. Montek LC PO BD
5. Tab. Azithromycin 500 mh PO OD 
6. Tab. Pulmo clear 100/600 PO BD
7. Bronchodilator- salbitamol
8. Syp. Grillinctus 10 ml PO BD
9. Syp. Aristozyme 5 ml PO BD
10. Nebulization with 
Ipratropium - 6th hrly (QID)
11. O2 inhalation to maintain saturation>90%
12. Monitor vitals.






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