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Hyndavi Konakanchi, 8th semester
Roll no: 63
January 13 , 2022
A CASE DISCUSSION ON 36 YR OLD MALE PATIENT WITH BREATHLESSNESS & DIFFICULTY IN SWALLOWING
I've 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 a diagnosis and treatment plan.
Following is the view of my case :
CASE PRESENTATION:
A 36 year old male patient who is a watchman in a govt. Hospital came to the casualty with the cheif complaints of breathlessness and difficulty in swallowing ( even saliva ) since 1 day
HISTORY OF PRESENTING ILLNESS :
Daily routine :
This patient who is watch man by occupation since 20 years, wakes up at 5 am in the morning and goes for a walk and have his breakfast around 8:30 am ( rice and curry ) — then he goes for covid duties ( like referring tests ) as his part time job since 2 years before that he used to stay at home — he will have his lunch at 1 pm — he will have tea at 5:30 pm — & goes for his watch man duty — will have dinner at around 8:30 pm and sleeps at 10 pm ( He takes sound sleep of 8 hrs )
He has good relationship with his family and friends
He was married 16 years ago and he had 2 girl childs
Patient was apparently asymptomatic before 2007 and then he developed breathlessness and difficulty of swallowing ( even saliva ) , following that he noticed swelling of uvula for which he went to hospital in miryalaguda , they referred 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 swellings when exposed to smoke/dust/perfume/alcohol smell/while cooking , when he eats certain foods (mutton,fish,brinjal,sorrel leaves).
Swellings usually appear 5 to 10 hours of exposure to triggers
Patient also gets the edema when he is stressed if they're any fights or loud voices.
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 history of decreased frequency of urination , peri orbital edema , burning micturition.
PAST HISTORY:
Not a known case of DM/HTN/TB/BA.
No history of any other surgeries
FAMILY HISTORY:
No similar family history
ON EXAMINATION:
Patient is c/c/c
No signs of pallor or cyanosis or clubbing or icterus or koilonychia or lymphadenopathy.
Edema of the limbs : absent
Edema of uvula & larynx : present
Edema of the 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
HERIDITARY ANGIO EDEMA
TREATMENT :
On day 1 of presentation
On day 2 of presentation
1. INJ. HYDROCORTISONE 100 MG IV BD
2. NEB with ADRENALINE QID
3. Plan for Fresh frozen plasma administration
On day 3 ( after administering FFP , uvula became normal )
Treatment advice by ent department:
1. INJ. HYDROCORTISONE 100 MG IV QID
2. NEB with BUDECORT and ADRENALINE
3. Head end elevation.
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