PRESENTED BY: SITI HAJAR MAIZURAH & NURSHUKRIYAH HAJAR ‘SUPERVISED BY: DR. NUR IZAT MUHAMAD01 - HISTORY TAKING PATIENT’S IDENTIFICATION Name Registration No. : Age 56 years old Sex : Female Ethnic : Malay Occupation : Housewife Address Date of Admission —_: 17/05/2022 Date of Clerking : 22/05/2022 Informant : Patient HerselfCHIEF COMPLAINT Patient presented to Emergency Department HUSM with shortness of breath for 3 days prior to admission HISTORY OF PRESENTING ILLNESS (HOPI) Underlying: Asthma, Type Il diabetes mellitus, hypertension, dyslipidaemia Coug! Onset: Acute (x 3 days) Preceding event: Resting Nature: Productive cough - % teaspoon, thick yellowish sputum, no blood stained, non-purulent Patter: Persistent throughout the day but worsen at night Associated symptom: Chest tightness (non-radiating) Relieving factor: Strepsils (temporary) - denied taking any cough syrup Progression: dry to productive cough and worsen in frequency Otherwise: No night sweat, no sore throat, no nausea and vomiting, no abdominal pain, no weight loss, no history of COVID-19 infections and close contact, no TB sick contact, no chest pain, no paroxysmal nocturnal dyspnoeaShortness of Breath: Onset: Gradual Character: Intermittent Timing: throughout the day Associated symptoms: Chest tightness (not radiates to back or left shoulder or jaw), audible wheezes at night, cough, fever Relieving factor: Bronchodilator (Symbicort - 2 puffs) - on the day of admission; not relieved Severity: Reduced effort tolerance, able to speak in phrases Otherwise: Deny foreign body inhalation, no history of fall, no trauma, not a smoker, deny alcohol abuse and intravenous drug use Fever: © Fort day © No chills & rigor Temperature not recorded Relieved by PCM At Emergency Department: Given nebulizer thrice Partially relieved her symptoms Admitted to 7U for further management and investigationBronchial Asthma Adult-onset Diagnosed 6 years ago at HUSM Presented with shortness of breath and wheezing Spirometry was done Husband was a smoker Lives near main road Currently on Symbicort 2 puffs twice daily (claimed to be compliant) Last admission: during diagnosis Allergic rhinitis since child Triggering factors: Cold, dust Sleep with 2 pillows Dyspnoea upon exertion - walking, climbing up stairs, lifting objects Asthma control: Well-controlled Denies eczema, family history of asthmaSystemic Review Respiratory System . As mentioned in HOPI Musculoskeletal System + No muscle or joint pain + Nojoint swelling + No deformities Cardiovascular System + Nopalpitation + Noankle oedema Central Nervous System . No dizziness . No numbness . No loss of consciousness Gastrointestinal System + No abdominal pain + Nonausea and vomiting Haematological System + Noeasy bruising + Nobleeding tendency + Nopallor Genitourinary System + No dysuria + Frequent micturition + No changes in urine colour Endocrine System + Nopolydipsia + Nopolyphagia + Noneck swellingPAST MEDICAL AND SURGICAL HISTORY Hypertension © Diagnosis: 2018, KK Wakaf Che Yeh © Under follow up, deny any admission, compliant to medication ‘Tye Il Diabetes Mellitus ‘© Diagnosis: 2019, KK Wakaf Che Yeh during follow-up Under follow-up, compliant to medication, no hypoglycaemia episodes, no complication © Monitor BSP at home - 1-2 per week (suboptimized) © Practice diabetic diet Dyslipidaemia © Diagnosis: 2020, KK Wakaf Che Yeh © Under follow-up, compliant to medication *Never underwent any surgical procedure beforeOBSTETRICS AND GYNAECOLOGY HISTORY Attained menarche at age of 13 years old Regular menstrual cycle 6 to 7 days in a 28 to 30 days cycle Complained of mild dysmenorthoea, took paracetamol to relieve her pain Otherwise: No abnormal vaginal discharge, no menorrhagia, no intermenstrual bleeding, no gynaecological pathology Menopause: 54 years old Denied taking any hormonal replacement therapy DRUG HISTORY T. Metformin -2 tablets BD T.Gliclazide- 1 tablet ON T. Amlodipine - 1 tablet ON T. Simvastatin - 40 mg ON Denied taking supplement, over-the-counter drugs and traditional medications No known drug allergyDIETARY HISTORY Health-conscious Control sugars, fats and salts Well-balanced diet, rarely consumes sugar (brown sugar only), eat once per day, eat vegetables and fruits Love bananas Young - allergic to prawn; itchy Otherwise: No known food allergy FAMILY HISTORY 1st child out of 4 siblings (non-consanguineous marriage) Father - 84 years old, well and healthy Mother - passed away (could not recall the exact year), had hypertension and T2DM All siblings have T2DM and hypertension except for her brother (no T2DM but has gouty arthritis) No family history of asthma, chronic lung disease, cardiovascular disease, autoimmune or malignancyPERSONAL AND SOCIAL HISTORY A housewife Married at 21 years old, blessed with 4 children (3 male, 1 female), SVD Husband - was a smoker, passed away in 2010 due to MVA Currently lives in single-storey house at Wakaf Che Yeh with her son and family (5 people) Good electrical and clean water supply from the government (Claimed occasionally used well) No financial aid Completed COVID-19 vaccination (3 doses), no history of COVID-19 infectionSUMMARY Patient, 56 years old housewife with underlying asthma, type II diabetes mellitus, hypertension and dyslipidaemia was presented to Emergency Department HUSM with worsening shortness of breath for 7 days prior to admission associated with chest tightness, productive cough and fever. Otherwise, she denied any chest pain, no night sweats, no TB sick contact and no history of COVID-19 infection.RAE Vee General Examination Conscious, well oriented, not in pain, no sign of respiratory distress Nutritional and hydration status seems adequate, patient is not pallor Branula was attached at the dorsum of the left hand, no deformity and muscle wasting Vital sign Blood Pressure : 131/73 mmig Temperature : 37.2 Respiratory rate : 20 bpm Pulse rate : 113 bpm spo2 : 96%Hand Oral cavity © Palm was pink, warm and moist No peripheral cyanosis *® Good oral hygiene © No finger clubbing ¢ No oral thrush . * No central cyanosis © No tar staining * No muscle wasting Trachea * No fine tremor, no flapping tremor © No bruises and scar * No tracheal deviation Eye ave Xanthelasma at both eyes © Not raised Conjunctiva is pink No yellow discoloration of sclera Leg * No pedal edemaRespiratory Examination Anterior Chest Wall Inspection '* No discoloration of the skin No chest abnormality Chest move symmetrically with respiration Palpation '* Good chest expansion vocal fremitus normal ¢ Resonant at both lung auscultation honed at both Lung * Coarse crepitation bilateral at lower zone Prolonged expiratory phase © Vocal resonance normal Posterior Chest Wall Inspection ‘* No discoloration of the skin © No tenderness at the spine area Patpation ‘© Good chest expansion © vocal fremitus normal Percussion Resonant at both lung auscultation © Rhonei at both lung * Coarse crepitation bilateral at lower zone * Prolonged expiratory phase Vocal resonance normalSummary of Physical examination The patient was lying comfortably at 45 degrees supported by one pillow. He was alert, conscious, not in pain, not in respiratory distress and well oriented to the time, place and person. On general examination, xanthelasma was noted on both eyes. During respiratory examination, on auscultation, rhonci can be heard at both lung and coarse crepitation can be heard bilateral at the lower zone. There is also prolonged expiratory phase. There were no positive findings in specific examinations for other systems.UEFA PROVISIONAL DIAGNOSIS Acute exacerbation bronchial asthma secondary to community acquired pneumonia Relevant Positive Relevant Negative Shortness of breath Productive cough Worsen at night Generalized ronchi Fever Coarse crackles Prolonged expiratory phase Chest tightness? No dullness on percussion Symmetrical chest expansion No history of sick contact Non-purulent sputum No chest painDifferential Diagnosis Productive cough Diagnosis Relevant Positive Relevant Negative Acute Bronchitis, Shortness of breath Not a smoker Cough (Dry to productive) Not exposed to triggering Chest tightness, inritants Wheezing Fever Pulmonary Tuberculosis Cough No night sweats Shortness of breath No weight loss Fever No loss of appetite No haemoptysis No sick contact with TB patient Pleural effusion Shortness of breath No pleuritic chest pain No stony duliness to percussion No reduced breath sounds Present of tactile fremitus No pericardial rubBronchiectasis Productive cough No haemoptysis Shortness of breath Non-purulent sputum Coarse crackles No chest pain Wheezing No clubbing Heart failure Shortness of breath No fine crackles Cough No adventitious heart sounds Orthopnoea (S3 and $4) No pedal oedemaWEAN VECO 2. Arterial blood gas (fully compensated 1. Full blood count (WBC slightly increased) respiratory alkalosis) Resut | Nocmal Range | Unt Result | Normal Range wae | 12 ant X10 oH 7423. 1735-745 RBC | 538 45-55 % peo2 =| 319, 36-45 Hb 44a 13-17 % po2 65.1 75-100 mev | 809 22-98 % mck | 262 27-32 XA0'6ML 802 95.4 > 95 che | 324 31-35 gia. Hoos | 224 22-26 HeT | 435 40-50 % pur | 251 480-400 X10,3. CRP 6. Liver function test (raised transaminase) © Positive (52mg/L) (n=<10mg/L) Result | Normal Range 4 Blood cvs pos 1.28 | 087-145 © So far no growth (SFNG ® (sine) Albumin | 42 38-44 5. Renal function test AST / 121 5-34 Result | Notmal range Na 138 130-145 Ae ‘80 £3. 128 K 39 33-61 AT | 1st | <5 Urea 35 14-72 7. Coagulation profile Creatinine | 67 58-127 Result | Normal range PT 128 | 126-157 INR 094 | 0.86-1.14 aPTT 296 =| 30-458ECG Sinus. regular rhythm HR : 106bpm (tachychardia) Axis: normal axis Normal ECGChest X-Ray ay * Bilateral haziness at lower zone * No cardiomegalyUae a aN ONauURWNE NPO2 3L/min (keep Sp02 > 95%) Neb combivent 4 hourly Neb salbutamol 4 hourly IV Hydrocortisone 100mg TDS T. Bromhexine 8mg TDS IV Augmentin 1.2g TDS T. Azithromycin 500mg OD Continue old medication Tr. T. Gliclazide - ON Tr. T. Simvastatin - 40 mg ON Metformin ~ BD Amlodipine - ON