A76 year old female presented with complaints of difficulty in breathing and left sided flank pain.

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CHIEF COMPLAINTS 

A 76yr old female resident of parvatipuram homemaker by occupation came yesterday with chief complaints of shortness of breath since 4months  and pain in the left side of the flank since 10days.

HISTORY OF PRESENTING ILLNESS.

Patient was apparently asymptomatic 5months back and then she developed shortness of breath that progressed from grade-2 to grade-3. 

It was not associated with orthopnea or paroxysmal nocturnal dyspnea and no complaints of pedal edema.  

lesions are seen over the left lumbar region since 10days where pain is associated, for which she visited rmp and  took some unknown medicine. 

The lesions are painful.There is no h/o blisters , fever and no other areas are involved.

There is pain in the left side of the flank since  10days.pain is burning type and not radiating and has no aggregating or relieving factors . 

There is also complaints of nodding of the head.

HISTORY OF PAST ILLNES.

There is similar history in the past, which subsided on medication.

She is a known case of asthma, hypertension, and not a known case of diabetes,epilepsy and thyroid disorders.

TREATMENT HISTORY

She is diagnosed with hypertension nearly 30years back, and was prescribed medication but did not use them regularly and stopped the medication 4months back as directed by the doctors.

She used the inhaler at the time of attack.

FAMILY HISTORY

There is significant family history.

DRUG HISTORY

There are no known allergies for any drugs or food particles.

PERSONAL HISTORY

DIET :- Mixed

APPETITE:-normal

BOWEL & BLADDER HABITS :- regular 

SLEEP :- slightly decreased 

ADDICTIONS :-no 

MENSTRUAL HISTORY

She attained menopause.

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative. Moderately built and moderately nourished.

There is pallor and  no signs of icterus, cyanosis , clubbing, koilonychia, lymphadenopathy and pedal edema.

Vitals 

Temperature:- afebrile 

B.p:-130/90mm of hg 

Pulse:- 84bpm 

R.R :-  16 cpm 

SYSTEMIC EXAMINATION

C.V.S 

 S1 , S2 heard. No thrills or murmers heard.

RESPIRATORY SYSTEM 

Inspection 

Shape of the chest:- elliptical 

Type of breathing:- thoracoabdominal type. 

Palpation

Position of trachea:- central. 

Auscultation

Normal vesicular breath sounds are heard.

Wheeze is present.

Added sounds:- not able to hear.

ABDOMEN 

Inspection 

scaphoid abdomen , no engorged veins.

lesions with crusting over the left side of the abdomen.

Palpation 

On P/A :- soft and pain in the left lumbar region of the abdomen extending towards left side.

Auscultation

Bowel movements are heard.

C.N.S 

No focal neurological deficits.

Speech is normal 

Reflexes

Biceps :- ++

Triceps :- ++

Supinator :- ++

Knee :- ++

Ankle :- ++ 

 INVESTIGATIONS 

PROVISIONAL DIAGNOSIS 

Chronic bronchial asthma with lesions of herpes zoster,  cyst in the right kidney, and nodding of the head.

TREATMENT GIVEN

1. Tab. Amoxiclav 625mg

2. Tab. Pan 40 mg 

3. Tab. Ultracet 1/2 tab (qid)

4. Tab. Tetrabenzene 12.5mg

5. Nebulizer with salbutamol ]2 respules

                                Budecort ] 2 respules 

6. Monitoring the vitals.