A 36 YEAR OLD MALE PATIENT WITH BREATHLESSNESS AnD DIFFICULTY IN SWALLOWING

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Name : K. Supriya (9th semester)

Roll number : 53 

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.

A 36 YEAR OLD MALE PATIENT WITH BREATHLESSNESS AND DIFFICULTY IN SWALLOWING

 Amc bed 1

A 36 year old male patient who is a watchman in a govt. Hospital came to the casuality with 

C/C of  BREATHLESSNESS and 

             DIFFICULTY IN SWALLOWING (even with Saliva )  Since 1 day .

Hopi:

This patient ,who is watchman by occupation since 20years ,wakes up at 5am in the morning ,goes for a walk and have his break fast at 8:30 am (rice &curry ),then he goes for COVID DUTIES (like reffering tests ) as his part time job since 2years ,before that he used to stay at home and have his lunch at 1:00pm (rice & curry),and have tea at 5:30 pm and goes to work as watchman ,and have dinner at around 8:30 pm and sleeps at 10:00pm (takes sound sleep of 8hrs). He has good relationship with his family ,friends .

                  He married 16years ago and have 2 girl child. 

Patient was apparently asymptomatic before 2007 and then he developed breathlessness and difficulty in swallowing (even with Saliva )  he also noticed  swelling of uvula ,for which he went to  hospital in miryalguda.

      They reffered him to  hospital 2 (our management) where tracheostomy was done .     

Since then he had multiple episodes of edema  for which he took hydrocortisone and avil at home and if there was any episode of breathlessness and difficulty in swallowing  he came to hospital.

** Tracheostomy was done twice in the same hospital in 2007 & 2016. ( at both instances he developed edema of uvula ) 

— He also had multiple episodes of edema of limbs and face which resolved on its own at home 

— Last episode of edema of face in December 2020

Patient usually develops edema when exposed to smoke/dust/perfume/alcohol smell/while cooking , when he eats certain foods (mutton,fish,brinjal,sorrel leaves).and also when he is stressed if they're any fights or loud voices.

Edema  usually appear 5 to 10 hours of exposure to triggers .

Episodes are more in winters than in summers.

Patient is taking all precautions so he won't have an episode again but he is scared that he will have another episode as he has many triggers and his sleep is disturbed from an year.

 

No H/O decreased frequency of micturation .

No  H/O peri orbital edema .

No H/O Burning micturation 

Past history:

Not a k/c/o DM/HTN/TB/BA.

No history of any other surgeries 

Family history:

No similar family history

O/e:

Patient is conscious ,coherent and cooperative .

No signs of pallor or cyanosis or clubbing or icterus or koilonychia or lymphadenopathy.

Edema of limbs absent .

Edema of larynx present .

Edema of uvula present.

Vitals : 

Temperature: Afebrile 

Pulse Rate: 115 beats per minute 

Blood pressure: 120 / 80 mm Hg 

Respiratory Rate: 22 cycles per minute 

SpO2: 98 % on room air

Systemic Examination: 

1) RESPIRATORY SYSTEM : 

* Chest is symmetrical and there are no chest deformities 

* No wheeze, no crepts

* Bilateral air entry is present 

* Normal vesicular breath sounds are heard 

* Equal movements on both sides on respiration 

2)CVS: 

* S1 and S2 heart sounds are heard

* No murmurs 

3) ABDOMINAL EXAMINATION:

* All quadrants of abdomen are moving equally with respiration 

* Abdomen is soft & non-tender

* Bowel sounds are normal

4) CNS: 

* No focal neurological deficits 

* Higher motor functions are normal 

Investigations : 

Diagnosis:

HEREDIATARY  ANGIO  EDEMA 

Treatment:

1. INJ. HYDROCORTIONE 100 MG IV BD

2. NEB with ADRENALINE QID

Planning for FRESH FROZEN PLASMA Administration .

Day -1: 

Day -2: 

Day -3: ( after giving 3 bottles of fresh frozen plasma ) .

Treatment advice by ent department:

1. INJ. HYDROCORTIONE 100 MG IV QID

2. NEB with BUDECORT and ADRENALINE

3. Head end elevation