Case Presentation on a medicine case scenario

Case Presentation

1. CLINICAL CASE PRESENTATION BATCH G MUHAMMAD ARHUM ARHAM REHMAN OSAMA AHMED

2. PATIENT PROFILE & PRESENTING COMPLAINT Patient Matloob Bibi,50 year old female housewife, resident of Tarnol , presented to ER on 15th October 2024 with chief complaints of 1.Shortness of Breath for 15 days 2.Cough for 15 days

3. HISTORY OF PRESENT ILLNESS The patient reports that Shortness of breath started 4 years back which was gradual in onset associated with cough. The recent episode of SOB was 15 days back which was gradual in onset and worsen with time. Aggrevated by walking, mild exertion, cold weather, cold drinks, rice and lying flat at night time. It was relieved by coughing out sputum and sitting up. It was associated with cough, chest pain, mild fever and wheezing. The cough started 15 days back more at night time. It was associated with sputum which was white in colour , no blood, foul odouring and increased on lying around. Cough was associated with wheezing, breathlessness on exertion, chest pain, mild fever documented at 100 F and weight loss. It was aggrevated on eating rice and chicken, drinking cold drinks and exposure to dirt. It was relieved by use of inhalers and drinking hot beverages.

4. SYSTEMIC REVIEW Cardiovascular: No Palpitation, No orthopnea, No peripheral edema, no cyanosis Respiratory: Cough, wheezing, sputum production and SOB. Gastrointestinal: No Abdominal distension, No Diarrhea, No Vomiting. Genitourinary: unremarkable no Nocturia, no hematuria and no dysuria Neurological: No history of stroke, no headache or seizures. Endocrine: weight loss no hx of cold intolerance Musculoskeletal: Unremarkable no joint pains and stiffness

5. PAST MEDICAL & SURGICAL HISTORY No history of TB, IHD, HTN and DM. She underwent Hysterectomy 5 years back.

6. PERSONAL AND SOCIAL HISTORY Dirt Allergy Good appetite Good sleep

7. FAMILY HISTORY AND SOCIO ECONOMIC HISTORY. History of TB in 2 Sisters. History of asthma in mother and grandmother. She has 4 sons and 1 daughter. She lives in her own house and belongs to a middle class family.

8. MEDICATION HISTORY Inhaler (Fluticasone)

9. BLOOD TRANSFUSION HISTORY No history of blood transfusion.

10. GENERAL PHYSICAL EXAMINATION On general physical examination, my patient was lying comfortably well oriented in time, place and person. 1. Vital Signs: - Blood Pressure: 140/90 mmHg - Heart Rate: 88 bpm - Respiratory Rate: 20 breaths per minute - Temperature: 98.6°F (37°C) - Oxygen saturation is 93 at room air She had no pallor, jaundice, anemia, clubbing, koilonychia, lymphadenopathy, edema and tremors.

11. RESPIRATORY SYSTEM On respiratory system examination, the chest was bilaterally symmetrical in shape with normal respiratory movements. There were no scar marks, masses, or skin changes. On palpation, the trachea was central and chest expansion was bilaterally equal. The percussion note was bilaterally resonant. On auscultation, there was normal vesicular breathing and bilateral wheezing was heard.

12. DIFFERENTIAL DIAGNOSIS Asthma Seasonal Allergy

13. INVESTIGATIONS Laboratory Tests Complete Blood Count (CBC) : To check for signs of infection (elevated white blood cells) or anemia. Basic Metabolic Panel (BMP) : To assess kidney function and electrolyte balance. C-reactive protein (CRP) : To evaluate for inflammation.

14. INVESTIGATIONS Imaging Studies Chest X-ray : To identify any signs of pneumonia, pleural effusion, or other structural lung diseases. CT scan of the chest : If the X-ray findings are abnormal or if there is a high suspicion of conditions like pulmonary embolism or interstitial lung disease.

15. INVESTIGATIONS Pulmonary Function Tests (PFTs) To evaluate for obstructive or restrictive lung disease, especially if asthma or COPD is suspected. Microbiological Tests Sputum Culture : If productive cough is present, to identify bacterial infections. Nasopharyngeal swab : For viral infections, particularly if there’s a history of recent respiratory infections.

16. MANAGEMENT PLAN Symptomatic Treatment Bronchodilators : If there’s evidence of bronchospasm (e.g., wheezing), use short-acting beta-agonists (e.g., albuterol). Cough Suppressants : If cough is dry and causing discomfort, consider cough suppressants. Avoid them if there’s productive cough with mucus.

17. Antibiotics If a bacterial infection (e.g., pneumonia) is diagnosed based on clinical judgment and sputum culture results, initiate appropriate antibiotics. Common choices may include: Amoxicillin or Azithromycin for community-acquired pneumonia. Levofloxacin or Ceftriaxone for more severe cases.

18. Corticosteroids Consider corticosteroids (e.g., prednisone) for inflammatory conditions like asthma exacerbation or acute bronchitis, especially if wheezing or significant inflammation is present.

19. MONITORING AND FOLLOW-UP Follow-Up Schedule follow-up appointments to monitor symptoms and response to treatment. Adjust treatment based on progress and any new findings. Patient Education Educate the patient about recognizing worsening symptoms (e.g., increased shortness of breath, chest pain).