75 yearl old female with nstmi with acute exacerbation of asthama

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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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

Case presentation 

Patient was brought to the casualty with a/h/o shortness of breath since 10 days and dry cough occasionally

Hopi 

Pt was apparently asymptomatic 10days back then she developed sob which was insidious in onset (mmrc2) not associated with wheeze aggrevated on exposure to dust and cold

Orthopnea present no pnd

Pt also has dry cough since one week occasionally 

No aggrevating and relieving factors 

Past history 

History of similar complaints since 10 years 

Pt on rota inhaler

(Fluticazone and vilantrol )

No h/o htn epilepsy tb 

Dm since 5 years not on any medication 

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-none 

GENERAL EXAMINATION 

Patient is c/c/c , moderately built and nourished 

No pallor, icterus, cyanosis ,clubbing,  lymphadenopathy, pedal edema 

Vitals:

Temp- afebrile 

PR- 78bpm

BP- 110/70 mmhg 

RR- 18cpm

SpO2- 97% at RA 

SYSTEMATIC EXAMINATION 

RESPIRATORY SYSTEM EXAMINATION 

URT

Oral cavity-  hard palate , soft palate,  uvula , tonsils , posterior pharyngeal wall - normal 

Dental caries present 

Nose - No septal deviation or Nasal polyps 

LRT

1.INSPECTION 

Shape of the chest - elliptical 

There is drooping of shoulder towards left side

Trachea appears to be central 

Equal movement of chest wall on both sides

No usage of  accessory muscles 

No scars ,sinuses ,engorged veins, edema 

2.PALPATION 

No local rise of temperature  , no tenderness 

Trachea central

Movement of chest wall  equal

Vocal resonance and tactical fremitus equal on both sides

Auscultation- Bae present nvbs present 

Coarse crepts present in b/l ica ma isa infra isa iaa

Investigation 

Culture- no growth 

Sputum - streptococcus pneumonia 

Hb-11.5

Tlc-21,000

Rbc 4.1

Platelets 2 lakh

Urea 100

Creat 1.4 

Na 135

K 3

Cl98

Provisional diagnosis 

Cad - NSTMI acute exacerbation of asthama with dm 2

Treatment 

Inj augmentin

Tab azitheomycin

Inj hai

Inj nph 

Inj heparin

Inj lasik

Tab ecosporin

Tab rosvastatin

Tab clopidogrel

Tab mucinac

Tab montec lc

Syp grylinctus

Syp potchlor

Neb budecort

Tab prednisone