A CASE OF 28 YEARS OLD FEMALE WITH COUGH AND 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 28 year old female who is a home maker, resident of Nalgonda, came to the General medicine OPD with chief complaints of 

• Cough since 1 week
• Shortness of Breath since 1 week

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 1 week back. Then she developed cough which was non productive and aggravated at night. 

She also complained of Shortness of Breath since 1 week which was insidious in onset, gradually progressed from mMRC grade II to grade III, associated with wheeze, palpitations, sweating and Orthopnoea. 

C/o chest pain which was dragging type, non radiating on the left side associated with chest tightness 

C/o fever 1 week back, subsided with medication.

There is no h/o loss of appetite, reduced urine output or loss of weight

PAST HISTORY:

No similar complaints in the past
No h/o inhaler usage
No past h/o TB
N/K/C/O HTN, DM, epilepsy, CAD, asthma
H/o 2 previous LSCS.

PERSONAL HISTORY:

Diet: Mixed
Appetite: normal
Sleep : Disturbed 
Bowel: regular
Micturition: normal
No addictions
No known allergies

Daily Routine:

She wakes at 6 AM in the morning and does her morning routine , household works and have breakfast by 9 AM after sending her kids to school and husband to work. She watches TV from 10 am to 12 pm and then prepares lunch by 12:30 .Eats  lunch at 1PM .She takes a nap from 2 pm to 4pm,wakes up at 4 pm, talks with neighbours. Her kids and husband return home by 5PM . At 5'o clock she Drinks tea with some Snacks like biscuits. From 5: 30 pm she talks to her husband and asks about his day, prepares dinner at 7 pm and eats at 8pm , watches TV for one hour and Sleeps by 10pm.

FAMILY HISTORY:  not significant

MENSTRUAL HISTORY:

Age of menarche: 12 years.
Cycle: 3/28
Not associated with pain or clots
LMP: 1/12/22

OBSTETRIC HISTORY:

Age of marriage: 18 years
Age at first child birth: 22 yrs
Para: 2
Number of living children:3
Birth history: LSCS

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative and well oriented to Time, Place and Person.

No Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy or edema

 

No malnutrition or dehydration

VITALS:

Temp: Afebrile
PR: 126 bpm
BP: 130/90 mm Hg
RR: 38 cpm
SPO2: 98% at RA

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM: 

Patient is examined in a well lit room in sitting position.

Upper Respiratory tract:

Nose: No DNS, polyps, Turbinate hypertrophy
Oral cavity: no ulcers

Lower Respiratory Tract:

Shape of chest: elliptical
Trachea: appears to be central
Supraclavicular and infraclavicular hollowness absent
Accessory muscles usage  -
Apical impulse not assessed
No kyphoscoliosis
No hyperpigmented patches, scars

PALPATION:

All Inspectory findings confirmed
Trachea: Central
Tactile vocal Fremitus: Not assessed
Chest movements:Not assessed

PERCUSSION:

Direct: resonant
Indirect:Not assessed

AUSCULTATION:

Bilateral Air Entry +, Normal Vesicular Breath Sounds

CVS: 

S1 S2 +
No murmurs heard

PER ABDOMEN:

Soft, non tender
No Organomegaly

CNS:  No Focal Neurological Deficits

PROVISIONAL DIAGNOSIS:

Left sided hydro Pneumothorax

based on history and investigations on admission

INVESTIGATIONS:

CT SCAN CHEST

ElectroCardiogram

DAY 1: 1/12/22

Intercostal Drain inserted

Tube: Patent
Drain: 200ml
Air column: 3-4cm
Air leak +
Subcutaneous emphysema- Absent

Post procedure vitals:
PR: 128bpm
BP: 120/70mmhg
RR: 36cpm
SPO2: 99% with 12-14 litres/min of oxygen

Investigations

Chest X Ray Postero-Anterior View

Complete Blood Picture

Liver Function Tests

Renal Function Tests

C-Reactive Protein

 HbSAG Rapid Test

Anti HCV Antibodies - RAPID

 

TREATMENT:

1. High flow O2 @ 12-14 litres/min with face mask 
2. Inj PIPTAZ 4.5mg IV/TID
3. Inj PAN 40 mg IV/OD/BBF
4. Inj TRAMADOL 1 amp in 100ml NS stat
5. Syrup GRILLINCTUS-DX 2tsp TID
6. Inj ZOFER 4mg IV/STAT
7. T. DOLO 650mg PO BD
8. Monitor vitals- BP, PR, RR, SPO2

DAY 2: 2/12/22

DIAGNOSIS: Left sided hydro pneumothorax 

• C/o breathlessness reduced
• C/o pain at ICD site
• No c/o cough, fever, chest tightness, hemoptysis
• C/o Productive cough
  

On Examination:-

Patient is conscious, coherent, cooperative and well oriented to Time, Place and Person.
Temp: Afebrile
PR- 110 bpm
BP- 110/70 mmhg
RR- 40 cpm
SPO2- 98% with 4 litres of Oxygen, 93% @ RA
GRBS- 189 mg/dl

RS: BAE+, VBS
Crepts + - left MA, ISA, Infra SA
Rhonchi + - left MA, ISA, Infra SA

qSOFA score: 1

ICD NOTES:

Tube: patent
Drain: nil
Air column movement: 3-4cm H2O
No subcutaneous emphysema
Air leak- absent

Advice: 

Troponin I, sputum for CBNAAT, blood culture, urine culture, pleural fluid analysis, TLC, DLC, ADA, cytology

 

Investigations

2D Echo

 

TROPONIN I

Day 3 : 3/12/2022

 Pleural Cell Count

THYROID PROFILE

TREATMENT:

1.O2 inhalation @ 2-3l/min to maintain saturation >94%
2. Inj PIPTAZ 4.5mg IV/TID
3. Inj PAN 40 mg IV/OD/BBF
4. Inj TRAMADOL 1 amp in 100ml NS stat
5. Syrup GRILLINCTUS-DX 2tsp TID
6. Inj ZOFER 4mg IV/STAT
7. T. DOLO 650mg PO BD
8. Monitor vitals- BP, PR, RR, SPO2
9. ICD care:

• Bag always below waist
• Cap always open
• Check air column movement
• Maintain under water seal.

10. Nebulisation with DUOLIN-6th hourly, BUDECORT- 8th hourly
11. Tab. AZEE 500mg PO OD