79 Year Female with shortness of breath, Fever,cough,cold

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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Presenting complaints

Patient came to GM OPD with chief complaints of shortness of breath since 2days

Fever since 1month

Cough ,cold since 1month

HOPI:

Patient was apparently asymptomatic 1month back then she had fever low grade intermittent not associated with chills and rigor relieved by taking medication associated with generalised weakness.

Cough since 1month scanty sputum,non blood tinged, whitish in colour,non foul smelling

H/o shortness of breath since 2 days grade 2 aggravated on exertion relieved by taking rest.

No orthopnea, PND

No pedal Edema

H/o burning sensation in the oral cavity since 3 days

She has few ill-defined curdy white patches noted over bilateral buccal mucosa and soft palate.

Past history:

K/C/o asthma since 30 years using Formetrol and budesonide

N/K/C/o hypertension, diabetes mellitus type 2, Epilepsy, CVA, CAD,TB

Personal history:

Appetite normal

Sleep adequate

Bowels constipation present not passing stools for last 3 days

Micturition normal

General physical examination

Patient is conscious coherent and cooperative

Temperature 97.9F

PR 96 bpm

BP 130/80 mm hg

RR 18 CPM

GRBS 99 mg/DL

SpO2 94 %at RA

Systemic examination

RS Bilateral air entry present, bilateral crepts present in AA, IAA, MA, SSA, ISA

CVS S1S2 HEARD NO murmur heard

CNS HMI, NFND

P/A soft, diffuse tenderness

Diagnosis

Acute exacerbation of asthma

CKD

K/C/o Asthma since 30 years

Treatment

1.Nebulisation with ipravent 4th hourly budecort 8th hourly 

iv fluids NS @50 ML/HR
3.Inj hydrocort 100mg IV/bd
4.inj ceftriaxone 1gm IV/bd
5.TabMontek LC po/h/s
6.Tab pcm 650 mg po/sos
7.inj Hai SC/tid
8.syp.cremaffin 15ml po/h/s
9.syp potklor 15 ml in glass of water po/tid

10.candid mouth paint l/a BD x1week

11.nebulisation with mucomist 12 th hrly

12.Zytee gel Tid

13.nebulisation  with mucomist 12 th hrly