Patient : Gabriel

Age : 76
Presenting complaint Mr G, a 76 years old man with history of lung cancer is presented to ED
with SOB

History of presenting complaint The patient was admitted 6 weeks ago

He has dyspnea with mmrc class 3; that is with the distance of less than
100 m
He also have been coughing and produce sputum with minimum amount
of blood
The SOB is worse in the morning and on exertion and better at rest

Past medical history
He was diagnosed with lung carcinoma 4 weeks ago; a relapse
He has history of SCLC 18 years ago
He also have IHD, angina, heart valve disease, hypothyroidism, high
cholesterol and prostate adenoma in 2017
No HPTN, DM

Drug allergy No drug allergy

Currently on Tazocin, Tinzaparin, Allopurinel, disoprolol, Ipratropium
bromide, Lanzoprazole, Mirtazapine, Levothyroxine, Aspirin, Furosemide,
Osmolite, Prednisolone, Simvostatin, slow potassium, phosphate sandoz
Family history None

Social history Retired aircond repair

Stop smoking 40 years ago with 1 pack/ day but doesn’t remember when
he started to smoke
Drink occasionally

Systemic function enquiry No contributory symptoms

Exam Comfortable at rest, doesn’t seems to be in respiratory distress

On supplemental oxygen.Sputum pot, nebulizer, flutter valve and inhaler
was present
Patient is pink; no signs of cyanosis and jaundice
The patient was coughing frequently
 On hand examination, no signs of clubbing, pallar of plamar creases,
muscle wasting present
The hands was not too warm or cold.There was no asterixis but minor
tremor

On face examination, the eyes show no conjunctival pallor or any signs of

Horner’s syndrome (miosis; constricted pupil, anhidrosis; decreased
swearting, prosis; droopy eyelid)
No sign of central cyanosis for mouth
The trachea is not deviated and the crico – sternal distance is of 3 fingers
which is normal
The patients shows no raised in JVP

Upon chest inspection, no scar is present.But, there is injection brusing on

right flank
The apex beat is not displaced
The chest expansion is less than 3 cm
There was resonance bilaterally on percussion
Systolic murmur which radiates louder to apex than carotid is appreciated
on auscultation
There was no added lung sound
Sacral and pedal oedema was both absent

Vital signs
RR:16
SpO2 :96%
FO2:2L
BP:120/60
HR:76
Temp : 36.3

Summary This 76 years old man is presented with dyspnea accompanied by cough
producing small amount of flame.Systolic murmur radiating to both axilla
and carotid area is appreciated.My differential diagnosis would be
relapsed lung cancer, aortic stenosis and mitral regurgitation .
 Patient : X
Age : 72
Presenting complaint Mr X, a 72 years old man with history of motor neuron disease is
presented to ED with dyspnea

History of presenting complaint
Past medical history
The patient was admitted yesterday with dyspnea, tachycardia and cough
without sputum.
The dyspnea is grade 3 of mmrc score.Taking rest would make his
breathing better
He has been having problems to sleep since last 5 nights.
He also noticed hand tremor which he believed due to his alcohol
consumption
The patient is unable to speak; so we communicate by writing on paper
For past medical history, he was diagnosed with motor neuron bulbar in
2016.He also had salivary gland surgery and PEG tube insertion in the
same year

Drug allergy No drug allergy

Currently on co – amiclovax, clexane, prednisolone, pantoprazole, rinuzel,
atorvastatin, amelphylline, disonin
Family history No remarkable family history

Social history Retired farmer

Smokes 10 per day
Drink 2 unit alcohol per day
Lives alone but his cousin lives next door; who visits him on daily basis

Systemic function enquiry No contributory symptoms

Exam Comfortable at rest, doesn’t seems to be in respiratory distress

The patient is pink, not pallor.No other medical devices except for PEG
tube which is used for feeding
 The hands was not too warm or cold.There was no asterixis but minor
tremor
On hand examination, no signs of clubbing.Palmar erythema is present,
thenar eminence wasting present
Irregularly irregular pulse was appreciated.

On face examination, the eyes show no conjunctival pallor or any signs of

Horner’s syndrome (miosis; constricted pupil, anhidrosis; decreased
sweating, prosis; droopy eyelid)
Dry lips is noted
The patient was unable to open his mouth for examination
The trachea is not deviated and the crico – sternal distance is of 3 fingers
which is normal
No raised JVP is observed

Upon chest inspection, no scar is present.

The apex beat is not displaced
The chest expansion is less than 3 cm
There was resonance bilaterally on percussion
There was no added heart and lung sound
Sacral and pedal oedema was both absent

Vital signs
RR:17
SpO2 :97%
BP:130/80
HR:119
Temp : 37.3

Summary This 72 years old man with motor neuron disease is presented with
dyspnea accompanied by cough.On examination, tachypnea, thenar
eminence wasting and less than 3 cm chest wall expansion is
appreciated.It is crucial to monitor the patient’s symptoms such as
establishing his baseline of respiratory function and can be assisted with
strategies such as positioning, relaxation & anxiety management and also
breathing technique