A 45 year old female with cough and breathlessness
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Chief complaint:
A 45 year female resident of Nalgonda, shop keeper by occupation came to causality with a chief complaint of cough associated with sputum since 7days and Breathlessness since 7 days.
History of present illness:
Patient was apparently asymptomatic 1 month back then she developed cough with sputum which is aggrevated from 7 days. Sputum is mucoid, non blood stained , non foul smelling.
Seasonal variation-cough is more during nights
No postural variation associated with chest pain while coughing,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 history of loss of weight or loss of appetite
No similar complaints in the past
Known cause of Hypothyroidism since 5 months (Thyronorm 50mcg)
No history of Diabetes mellitus, Hypertension,Coronary artery disease , Epilepsy, Tuberculosis.
No History of inhaler usage in past
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 established 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% at RA litters of O2
GRBS: 132mg%
Systemic examination:
Upper respiratory tract examination:
Nose -Right sided turbinate hyper trophy
Left sided deviated nasal septum
Oral cavity- normal oral hygiene, posterior pharyngeal wall congested
Lower respiratory tract :
Inspection :
- shape of chest is symmetrical,elliptical
- Trial’s sign absent
- Supraclavicular and infraclavicular hollowness is absent
- Chest expansion equal on both sides
- No crowding of ribs,drooping of shoulders
- No usage of Accesory muscles of respiration
- Spinoscapular distance equal on both sides
- Apical impulse not seen
- No kyphosis / scoliosis
- No sinuses, scars, engorged veins, visual pulsations
Palpation :
All inspectory findings are confirmed with palpation.
Trachea central in position.
Apex beat felt at Left 5th intercoastal space, 2cm median to mid clavicular line
No local rise in temperature
No tenderness
Tactile Vocal Fremitus is equal on both sides
Chest movements: Equal on both sides
No crowding of ribs
Antero-posterior diameter- 23cms
Transverse- 21cms
I - 85cms
E-83cms
Right hemithorax- 44cms
Left hemithorax - 43cms
Percussion:
Direct resonance- clavicle and manubrium
Indirect resonance - resonant in all areas.
Auscultation:
Bilateral air entry present
Vesicular breath sounds
No added sounds
Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No
Apex beat felt at Left 5th intercoastal space, 2cm median to mid clavicular line
Investigations :
Provisional Diagnosis:
Bronchial Asthama
Treatment:
Tab.Azek 500mg OD
Tab.Montair LC (montelukast10mg +levocitrizine 5mg) OD
Syp. Ascoril 2tsp BD
Tab pantop 40mg OD
Tab paracetamol 650mg if temperature >99•F
