Ahmed abdul hadi

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History:
Mariam Mohammed Abo erjala is sixty-three year-old female, married with one son and
five daughters, lives in khozaa in Khan younis work as house wife .
She was admitted from ER to female medical ward in European Gaza hospital on
Wednesday 23/10/2013 at 6 PM.
The history was taken from the patient mother herself who was reliable and informative
by a sixth year medical students Ahmed abdul hadi.
File No. 191972

Chief Complaint: Cough and feverish sensation for 2 days.

History of Present Illness:
The patient is a known case of lung fibrosis and she was in her usual state of health
until two days prior to admission when she started to suffer from cough and feverish
sensation .
She suffered from many times of dry cough which change to productive cough. The
sputum was yellowish, offensive and about tea spoon in each time without blood or
frothy appearance.
It was progressive and more sever in the night without exaggerated or reliving factors.
She also complaining from shortness of breath which was more prominent in night and
when she was lying flat and it increased when she was walking about 5 m she also
suffered from paroxysmal nocturnal dyspnea.
Some time she also suffered from wheezing.
She also suffered from bilateral lower limb swilling which was progressive and increase
by sitting and relive when she was walking.
These symptoms were associated with feverish sensation which was contentious and
progressive and was not documented by patient.
She denies syncope, diaphoresis and vomiting.
There was no history of anorexia or weight loss.

Review of system:
Cardiovascular: no cyanosis; no history of murmurs.
GIT: no abdominal pain, no diarrhea, no constipation, no hematemesis.
Neurological: no seizures; no spasms.
Musculoskeletal: no pain and no fractures.
Endocrine: No heat or cold intolerance, no weight loss, no polyuria and no polydepsia

Past medical history:

Nine months ago, She suffered from dry cough and she was diagnosed and treated as
lung fibrosis and during this period she still suffer from multiple episodes of dry cough.
No history of other chronic disease.
No history of blood transfusion.
No history of surgical operations.

Drug history:

Steroids (cortisole) and Calcium.

Ahmed abdul hadi

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No history of drug or food allergy.

Family history:

No history of similar attack of his family.

No history of chronic disease in his family.
No history of sudden death.
No history of hereditary disease in his family.
There is no consanguinity between his father and mother.
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Social history:
Patient lives in the ground floor with her husband. They have good water, electricity
and ventilation. There are no pets in the home, and there are no smokers in his family.
They have medical insurance and his parents have secondary school level.

Physical examination:
Vital signs:
Temperature: 38 C
Pulse: 85 beat/min

Respirations: 22 cycle/min
BP: 110/70

General:

The patient looks well with cushingoid face, not comfortable and she still complaining.
There was no pallor no cyanosis and no jaundice.
Hand
There was first degree clubbing without any other abnormalities.
Chest:
Inspection: The patient was normal with symmetrical thoracic-abdominal respiration.
There are no skeletal deformities, no pectus carinatum, no pectus excavatem no visible
pulsation, no dilated vein, no scars and no pericardial pulging.
Palpitation: apex peat in the 5th intercostal space slight lateral to the mid clavicle line,
trachea centralize and chest expansion reduced at the right.
Tactile fremitus: increase at the right area.
Percussion: There was dullness at right fifth intercostal space and also dullness at the
base of the lung from the back.

Ahmed abdul hadi

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Auscultation: There was crackle, bronchial breathing, vocal resonance at right 5th
intercostal space and crackle at the base of the lung from the back.

Cardiac examination
Inspection:
Chest is symmetrical with thoraco-abdomenal respiration. There are no precordial
plugging or skeletal deformity, no visible pulsation, no sternotomy or thoracotomy
scars, no dilated veins
Palpitation:
Normal apex beat in the fifth intercostal space lateral to mid clavicle line and there is
no pulsation in the other area of chest.
There is no heave or thrill.
Auscultation:
Normal first heart sound, loud second heart sound, no murmurs, no click or other add
sounds.

Investigation
Chest x ray:
There was:
Obliteration of the right and left costophrenic angle
Reticular shape in the lower zone of the lungs
Infiltration in the right lower zone
CBC
WBC: 13.5 x 103 / UL
Gran:10.3
RBC:4.2 x 106 / UL
Platelet: 200 x 103 / UL
HGB: 12 g/dl
Urea: 45 mg/dl
Cr: 1.2 mg/dl

Management:
Definitive diagnosis: Acute chest infection (lobar pneumonia ) on top of lung fibrosis

Normal saline 500cc /8h

Cefuroxime 750mg TID
Ranitidine 50 mg TID
Acamol 500mg 2x3
Ventoline inhaler 1x3
Chest physiotherapy

Ahmed abdul hadi

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Follow up:
Next day the patient still complains of cough, dyspnea improves and the patient looks
will.
By examination of chest: its expansion improve and the severity of crackle decrease
After this the patient improves and then discharge on his medication for lung fibrosis
and antibiotic for pneumonia.