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History of Present Illness

The patient presented to the emergency room with shortness of breath, productive cough, and chest pain for the past two days which were exacerbated by dust, fumes, and smoke and a history of smoking for 30 years. On examination, the patient was tachypneic using accessory muscles with decreased breath sounds bilaterally and an arterial blood gas showing type II respiratory failure. Labs showed leukocytosis and the patient was started on nebulizers, steroids, antibiotics, and anticoagulation.

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Jehangir Khan
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660 views4 pages

History of Present Illness

The patient presented to the emergency room with shortness of breath, productive cough, and chest pain for the past two days which were exacerbated by dust, fumes, and smoke and a history of smoking for 30 years. On examination, the patient was tachypneic using accessory muscles with decreased breath sounds bilaterally and an arterial blood gas showing type II respiratory failure. Labs showed leukocytosis and the patient was started on nebulizers, steroids, antibiotics, and anticoagulation.

Uploaded by

Jehangir Khan
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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History Of Present Illness:

My Patient presented in Emergency Room with shortness of breath from the last 2 days.It was sudden
in onset.It was Grade IV in severity.It was relieved with rest and medications().And was aggrevated with
dust,fumes and smoke.

He also presented with productive cough from 2 days.It was gradual in onset.It was aggrevated with
dust,smoke and fumes and was relieved with medications(Cough syrup).The Sputum is Greenish/Whitish
in colour with foul smell.It was 2 cups per day.It has no relation with change in posture.Patient was
relieved with expectoration.

The patient also presented with chest pain from 2 days.It was a diffuse pain with no radiation and was
gradual in onset.It was aggravated with cough and was relieved with medications.

Systemic Review

General Complaints : Loss of appetite,Fatiguability,sleep pattern disturbed and fever(intermittent)

Respiratory Sys: Productive Cough,Dyspnea

CVS: Palpitations,Chest pain,SOB

GIT:Nausea,Bowel Habits(constipation)

GUS:Not Significant

CNS:Headache

MSK:Not Significant

Past History:

Medical History :- SOB (4-5 Yrs) ,Took medications prescribed by local physician

Surgical History:- Not Significant

Family History: Not Significant

Personal Hx:He is smoker from the last 30 Yrs with 30 pack year.No Pets or Biomass exposure

Socioeconomic Hx: He is a Labourer,Lives in a rented house in sector G-6/4 with good sanitation

GPE

He is sitting in the bed and uncomfortable.He has a cannula in his right arm.His GCS is 15/15

Pulse: 88 bpm with a regular pulse


GPE

He is sitting in the bed and uncomfortable.He has a cannula in his right arm.His GCS is 15/15

Pulse: 88 bpm with a regular pulse

R/R : 25/min

Temp: Afebrile

B.P : 150/90 mmHG (Fluctuating)

Jaundice –ive, Anemia -ive ,Clubbing -ive , koilonychia -ive , Lymph Nodes -ive , Edema -ive , Thyroid –
ive

Labs

TLC = 11700/ µL

RBC = 6.11 million/ µL

HB = 18.1 g/dL

Platelets = Normal

Neut % = 82.5%

LFTs = Normal

RFTs = Normal

Serum Electrolyte = Normal

ABGs with Oxygen

pH = 7.44

pO2= 52.4 mmHG

pCO2= 65.6 mmHG

HCO3= 38.1 mmol/L

Respiratory Examination

Inspection: R/R = 25/min

He was using accessory muscles when breathing,Apex beat was not visible,with not chest
deformity and no scar

Palpation : Trachea position = central


Respiratory Examination

Inspection: R/R = 25/min

He was using accessory muscles when breathing,Apex beat was not visible,with not chest
deformity and no scar

Palpation : Trachea position = central

Apex Beat = 5th intercoastal mid clavicular line

Chest Movements= Equal on both sides

Vocal Fremitus = Normal B/L

Percussion: Resonant on percussion B/L

Ascultation: Scattered Wheeze with ↓ air entry B/L

Vocal Resonance = Normal B/L

Medications

Nebs with Atem and Ventolin q6h

Inj Solucortef 100mg IV q8h

Inj Zithrax 500mg IV 1 x OD

Inj Risek 40mg IV 1 x OD

Inj Heparin 1cc s/c BID

Tab Unifyline 400mg ½ + 0 + ½

Case Summary

A 45 yrs old man presented in ER with the complaints of SOB , Productive cough and chest pain from 2 days.It was
sudden in onset and grade IV in severity.It was relieved with medications and rest and was aggravated with
Dust,fumes and smoke.He is a smoker with 30 pack years.He had a past medical Hx of SOB from the last 4-5 yrs
which was symptomatically treated by a local physician.His past surgical and family hx is not significant.He is a
labourer and economically poor.

O/E: He is tachypneic with R/R of 25/min,pulse of 88 bpm and a fluctuating B.P (150/90 mmHG) rest of the GPE is
normal.

Resp Exam: On inspection he was using accessory muscles with no visible apex beat or any deformity.On palpation
trachea was central with normal apex beat location and equal chest movements B/L. Percussion notes were
resonant B/L. On auscultation there was scattered wheeze and decrease air entry at the base B/L.
Labs : He has a TLC count of 11700/µL and HB of 18.1 g/dL with Neut (82.5%).His LFTs,RFTs and S.E are
normal.His ABGs shows Type II resp failure.

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