20year old lady with c/o difficulty in breathing since 20days

20/03/2023

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

Name:K. Thanmai (intern)

20year old lady from West Bengal came with the cheif complaints of

Difficulty in breathing since 20days

HOPI:

Patient was apparently asymptomatic 1 month back,then she developed cold and cough which lasted for 2 days and releived on medication.

Then after 1 week of this event her 3 months baby developed fever for which she admitted her baby in nursing home,the next day while feeding her baby she experienced difficulty in breathing and palpitations. She was unable to expire the inspired air and felt tightness and difficulty in her throat and chest which lasted for 10 minutes, for which she was administered oxygen in that nursing home and  the doctor there referred her to another hospital.

 Cardiologist where she got investigated and found to have minimal pleural effusion and pleural thickening on left side of chest in hrctfor which she was prescribed T.PROPRANOLOL 40mg,T.LIVOGEN Z,SYP.INDERAL LA 40.

And referred her to psychiatrist and ent surgeon for further evaluation.

the Psychiatrist prescribed T.OLANZEPINE 2.5 MGT,NEXITO FORTE,SYP.CYVIK 200ML,T.MEMAFER XT.

The ENT surgeon did fiberoptic laryngoscopy where she was found to have congestion of bilateral glossoepiglottic folds and bilateral aryepiglottic folds folds and interarytenoid area area and diagnosed her as having laryngopharyngeal reflux disease and prescribed her XYLOMETAZOLIN nasal spray and also found to have DNS for which he suggested surgery .

No h/o cough,cold

No h/o fever

No h/o orthopnea and pnd

No h/o decreased urine output

No h/o pedal edema 

PAST HISTORY:

No similar complaints in the past.

Not a known case of DM2,HTN,TB,CVA,CAD,

EPILEPSY ETC

FAMILY HISTORY:

not significant 

GENERAL EXAMINATION:

Patient was examined after taking her consent 

Patient is conscious , coherent , cooperative , well oriented to time , place and person 

She is moderately built and nourished 

No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

VITALS

PR:- 84 bpm

BP:-100/70 mm hg 

RR:- 17 CPM

SYSTEMIC EXAMINATION:-

CVS:- S1S2 + , No murmurs

P/A:- SOFT,NT

RS:

ON INSPECTION:-

UPPER RESPIRATORY TRACT :-

No halitosis,dental staining of premolars, molars.,no flaring of alar nasi,nasal septal deviation to right side 

LOWER RESPIRATORY TRACT:

Elliptical chest

Trachea- appears to be in midline

No supraclavicular hollowing 

Infraclavicular flattening

No shoulder drooping

No kyphoscoliosis,no lordosis

Chest movements appears to be b/l symmetrical

No visible scars/sinuses/dilated veins,no intercostal retractions or swellings

ON PALPATION :-

Trachea confirmed to be central in position

Apex beat- 1 cm medial to mid clavicular line in lt 5th intercostal space 

Chest movements- b/l symmetrical 

Vocal fermitus-rt normal,left side mild decrease in mammary region

No rib crowding/bony tenderness

Measurements:

Circumference: 34 inches

Expansion: 3 cms

 Ap: 7.3 inches

Transverse: 9 inches

 ON PERCUSSION:

 On left side mild decrease of resonance

 ON AUSCULTATION:

B/L air entry present and Normal vesicular breath sounds

CNS:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- Both upper and lower limbs normal

                           Rt        Lt

Power-  UL:     5/5        5/5

                LL.     5/5       5/5

Reflexes          Right      Left

Biceps                 ++        ++

Triceps.              ++.        ++

Supinator           +            +

Knee.                   ++.      ++

Ankle                  ++.       ++

INVESTIGATIONS:

Hb:8.7g%

TLC:6,200cells/cumm

PLATELET COUNT:1.60laks/cumm

PCV:25.1

CUE:

SUGARS:NIL

ALBUMIN: NIL

Urea: 26.3 mg/dl

Creatinine: 0.73 mg/dl

Lipid profile:

Total Cholesterol:150 mg/dl

Triglycerides:119mg/dl

HDL:32

LDL:94.2

VLDL:23.8

LDH:301 U/L

LFT:

TB:0.60mg/dl

DB:0.20mg/dl

AKP:91IU/L

SGOT:22U/L

SGPT:34 U/L

TP:6.6gm/dl

ALBUMIN:4.0gm/dl

A/G RATIO:1.54

Potassium: 3.5mEq/L

Calcium: 8.2 mg/dl

Vitamin D3: 26.9 ng/ml

RBS: 143 mg/dl

2D-ECHO(18/03/23)

EF:64%

IVC SIZE: 0.86cms collapsing

No AR,TR,MR,

No RWMA, NO MS/AS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION,NO PAH/PE

HRCT THORAX:(done outside)

IMPRESSION:

Minimal pleural effusion/pleural thickening on left side

FIBEROPTIC LARYNGOSCOPY:(done outside)

FINDINGS:

Base of tongue: normal

Vallecula:normal

B/l glossoepiglottic folds: congested

B/l aryepiglottic folds: congested

B/l pyriform fossa: normal

B/l true cords: normal,mobile,no phonatary gap

B/l false cords:  normal,mobile,no phonatary gap

Inter arytenoid area: congested

IMPRESSION:

Laryngopharyngeal reflux disease

ULTRASOUND ABDOMEN:

IMPRESSION:

Simple follicular cyst in left ovary

Chest X-Ray (PA view):

COURSE IN HOSPITAL:

DAY-1:(18/03/23)

Pt came to OP with above mentioned complaints and necessary investigations were done

DAY-2:(19/03/23)

ENT opinion taken in view of B/L nasal obstruction and discomfort in throat;

Patient was taken to ENT OPD :

Treatment advised:

1) OTRIVIN NASAL DROPS TID X 5DAYS

2)TAB.LEVOCET 5MG H/S

3) TAB.PAN 40MG PO/OD X1WEEK

Advised:

Review to ENT OPD for diagnostic nasal endoscopy on (20/03/2023)

DAY-3:(20/03/23)

DIAGNOSTIC NASAL ENDOSCOPY  (20/3/23)

Reporting of nasal endoscopy

1st pass: mild DNS to right with spur

                 mild high DNS to left

                           Rt.                     Lt

Inferior              N                      N

turbinate& meatus

Mucosa.              N                     N

Nasopharynx:    Grade I adenoid hypertrophy 

2nd pass:            N                   N

3rd pass:              N                   N

VLS:

Intra arytenoid area and arytenoids: minimal congestion

B/L vocal cords: mobile,symmetrical

B/L pyriform fossa: no pooling of saliva

Advised:

1)Continue above medication

2) Psychiatry counselling

Psychologist opinion taken and advised followed

DAY-4(21/03/23)

Discharging the pt today and we have advised her following treatment:

1.T.PROPRANOLOL 40MG PO/OD X 1 WEEK

2.T.LIVOZEN Z PO/OD X 1 WEEK

3.T.NEXTIO FORTE PO/OD X 1 WEEK

4.T.MEMAFER XT PO/OD X1 WEEK

5.MONTELEUCAST PO/HS X 1 WEEK

6.T.SPOROLAC PO/BD X 2days

7.T.LEVOCET PO/HS X 1 WEEK

8.SYP.INDERAL LA 40 PO/BD 10ML X1 WEEK

9.SYP.CITVIK 200ML PO/BD 10ML X1 WEEK

10.OTRIVIN NASAL DROPS TID X 5DAYS

PROVISIONAL DIAGNOSIS:

K/C/O LARYNGOPHARYNGEAL REFLUX DISEASE

WITH MILD RIGHT SIDED DNS WITH SPUR

WITH GRADE-I ADENOID HYPERTROPHY AND

ACUTE DIARRHOEA (RESOLVED)

TREATMENT GIVEN:

1.1 UNIT NS IV @100ML/HR

2. T.PROPRANOLOL 40MG PO/OD X 3days

3.T.LIVOZEN Z PO/OD X 3days

4.T.NEXTIO FORTE PO/OD X 3days

5.T.MEMAFER XT PO/OD X 3days

6.MONTELEUCAST PO/HS X 3days

7.T.SPOROLAC PO/BD X 3days

8.T.LEVOCET PO/HS X 2DAYS

9.SYP.INDERAL LA 40 PO/BD 10ML 

10.SYP.CITVIK 200ML PO/BD 10ML

11.ORS SACHET IN 1LTR OF WATER AFTER EVERY EPISODE

12.PLENTY OF ORAL FLUIDS

13.T.DOLO 650MG PO/BD(after checking temp)