60 year old female with history of SOB

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N.Deepa, 8th semester

Roll no. 93


I've 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 a diagnosis and treatment plan. 


Following is the view of my case :   (Admitted on 12/05/21 , 11 am) 

CASE :

        60 year old female came with the chief complaints of SOB since 2 days, cough since 2 days and giddiness since morning 6 am. 

HISTORY OF PRESENT ILLNESS :

            Patient was apparently asymptomatic 2 days back. Then she developed SOB which is of sudden in onset and progressive in nature. SOB is not associated with chest pain, palpitations, sweating, nausea, vomiting, blackouts, blurring of vision, Trauma to chest. 

She also has cough since 2 days. It is associated with sputum in small quantity. Patient attenders denied the history of fever, cold, sore throat, vomiting, loose motions, headache. 

Giddiness is sudden in onset and there is no change with change of position. 


PAST HISTORY :

              Patient is a known case of diabetes mellitus type -2 since 5 years.                                      No history of hypertension, epilepsy, tuberculosis, CVA, CAD. 


PERSONAL HISTORY :

Diet - mixed

Appetite - decreased

Bowel and bladder habits - regular

Sleep - inadequate


GENERAL EXAMINATION :

       Patient was conscious with glass gow coma scale of 11.

              GCS   

                   Eye opening - 4                                                               Verbal response - 1                                                        Movement - 6

No pallor

No Icterus

No Cyanosis

No Clubbing

No Generalized lymphadenopathy

No Bilateral pedal edema


VITALS :

Temperature : Afebrile

Pulse :  82 bpm

Respiratory rate : 32 cpm

Blood pressure : 120/90 mm of hg

Spo2 :  60% at room air

             88% with 5 litres of oxygen


SYSTEMIC EXAMINATION :

Cvs - S1 S2 heart sounds heard, No murmurs                    heard

Respiratory system - Bilateral course crepitus in                                        all areas heard


INVESTIGATIONS : 


1) Arterial blood gas ( ABG) 

             PH - 7.42

             PCo2 - 25.4 mm hg

             PO2 - 39.1 mm hg

             HCo3 - 16.1 mmol / lit

             St. HCo3 - 18.6 mmol / lit

             O2 saturation - 70.5 % 

             O2 Count - 11.5 vol%

            


DIAGNOSIS :

          SOB under evaluation
          Hypoxic encephalopathy??? 


TREATMENT : 

        • O2 Inhalation to maintain Spo2 >/= 90%
        • Nebulization with Budecort / Duolin - Stat               2 respules
        • Foley's Catheterization

As patient is in need of ventilator, patient has been referred to higher center. 

She has been discharged on the same day i.e.12/5/21  at  2.30 pm. 


She was taken to other hospital by the attenders where she was given oxygen inhalation for 2 days while they were waiting for a ventilator. 
CT was done in the same hospital and was informed that she has some problem in her intestines and referred to other center once they got a ventilator available. But she died before taking her to another center. 

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