85 FEMALE WITH SHORTNESS OF BREATH

19 August 2023

85 y/o FEMALE WITH SHORTNESS OF BREATH 


Hello!This is Srujana Yadavalli.
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. 


A 85 y/o housewife came to casualty with cheif complaints of -
shortness of breath since 3 days



HISTORY OF PRESENTING ILLNESS-

The patient was apparently asymptomatic 20 days back when she developed dizziness ,following which she fell down,resulting in injury to the right hip which was diagnosed as Rt.IT fracture and was admitted and provided with symptomatic treatment(5days)
Patient was bedridden and hence,developed Grade-3 bed sores in the gluteal region(rt) which were noticed yesterday
H/o generalised weakness associated with stoppage of food intake
H/o shortness of breath even at rest,orthopnea and PND which aggravated on talking 
H/o cough with mucoid expectoration since yesterday.
No h/o fever,cold,burning micturition,chest pain, palpitations,decreased urine output.

PAST HISTORY -
Not a k/c/o HTN/DM/EPILEPSY/TB/CVD and Asthma

FAMILY HISTORY -
Not significant

PERSONAL HISTORY-

diet -mixed
Appetite -decreased
Bladder and bowel movements -normal
Sleep -adequate
Addictions -tobacco chewing since 30 yrs 1/day
No known allergies.

MENSTRUAL HISTORY -
attained menopause
Age of marriage -16 yrs 
4 children -eldest being 20 years

SURGICAL HISTORY-
-ve


GENERAL EXAMINATION: 

Patient is conscious, coherent, cooperative to time , place, person.

Pallor: absent

Icterus: absent

Clubbing: absent

Cyanosis: absent

Koilonychia: absent

Lymphadenopathy: absent

Edema: right lower limb edema



Vitals: Temp: 99.4F

BP: 70/40 mmHg

PR: 121 bpm

RR: 21 cpm

SpO2: 90%



SYSTEMIC EXAMINATION:

    
CVS:
S1 S2 heard
No murmurs
No thrills

RS:
Dyspnoea present
 wheeze present 
Decreased air entry present 
Central position of trachea
NVBS +

ABDOMEN:
Shape of abdomen: scaphoid
No tenderness
No palpable mass
Hernial orifices: -
No bruits
Liver and spleen- not palpable
Bowel sounds heard

CNS:
Conscious
no neck stiffness



Investigations -
Cue-
Hemogram - 
ECG-
Chest x ray-
Rft-
Lft - 
2d echo-


Provisional diagnosis -
? Emphysema with k/c/o rt IT fracture 
Grade 2-3 bed sores?




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