Hospital: Zewditu Memorial Hospital City: Addis Ababa

Name: MOLA BEYENE Age: 50 Sex: M Occupation: None

Address: Addis Ababa, Around saris Marital Status: Married Religion :ORTODOX
Ward: Internal Medicine Room: Bed No: Card No:
EMERGENCY
Educational Status: READ AND WRITE Admission date: 29/6/24

Historian: the patient and his family Date of Clerking: 30/6/24

1. Identification
This is Mole Beyene a 40 years-old male who is married and practices orthodox religion. He lives in
Addis Ababa, around saris. Currently he has no Job. He went to Zewditu Memorial Hospital in the
emergency department on June 30, 2024. History was taken from the patient himself with no
language barrier.

2. Previous admission
• Mentioned on the HPI
3. Chief Complaint
 sob of 3 hr duration.

4. History of Present Illness

This is a 40 year old male known asthmatic patient for the past 10 years taking inhaled
corticosteroid beclametason twice daily and salbutamol puff whenever it is exacerbated patient
finishes one canister of salbutamol in 10 days when it is exacerbated patient claims to be adherent
to his medication. Pt was told that he has asthma here at ZMH after complaining of sob and chest
tightness he has 6 hospital admissions in the past 10 years and 2 emergency admissions in the past
6 months with no ICU admission or intubation his day time symptoms for the past month were
generally mild with occasional sob and wheezing during physical activity and night time symptoms
for the past week were more disruptive causing two to three wakening’s and requiring the use of
rescue inhaler. His last admission was two months back here at ZMH for the same compliant.

Currently he presented with sob that occurred at night around 12LT associated with that he had
chest tightness productive cough with whitish sputum of half Arabian cup, and audible wheeze
when asked what triggered the shortness of breath patient said it was exacerbated by cold .before
the occurrence of the sob he experienced stabbing type chest pain B/N his scapula and 3 days
before all this happened he had itching sensation over his throat.

.Otherwise: the patient has no history of:

- Orthopnoea PND or lower leg swelling

- Major surgery or immobility
- Smoking or drinking
- Recent loss of conciseness
- Similar illness in the family
- Skin rash or itching or discoloration
 - Recurrent runny nose

- Illicit drug use

- exposure to inhaled chemicals

- Seronegative for rvi

- DM HTN

5. Past illness

None

6. System Review

HEENT:
 Head: No trauma, Headache
 Eyes: there is vision loss of either eyes, No pain, strain, or photophobia
 Ears: No compliant of hearing loss, earache, discharge, deafness.
 Nose: No epistaxis, congestion and discharge
 Mouth and Throat: No history of dental pain, or bleeding from the gums. No throat or
postnasal drip.
Lymphoglandular system:
No mass in neck, axilla, groin.

Respiratory system:
MENTIOND IN THE HPI
Cardiovascular system:
No swelling of legs
No chest pain
No difficult of breathing

Gastrointestinal system:
No abdominal pain
No jaundice
No melena
No dysphagia
No Hematemesis

Genitourinary system:
No Urgency
No incontinent
No hesitancy
No dribbling
No hematuria
No pyuria.
 Integumentary system:
No Rash
No Ulcers
No nail changes

Musculoskeletal System:
No joint pain or swelling
No bone deformities

Central nervous system:

No Symptoms other than mentioned on the HPI

7. Personal History

Education Background: Education background can read and write.

Habits: He usually eats home product foods, like engera, Bread, etc.
Does not have any severe addictions
Has no history of Alcohol addiction and smoking

Family History

BORN AND RAISED IN WELDIA came to AA in 1991 now living with his wife and four children in a
well ventilated hose with separate kitchen and living room. And they are healthy. No family history
of similar illness.
8. Physical Examination

General Appearance

He appeared to be well looking, fully cooperative. He is not malnourished and doesn’t seem to be in
respiratory distress. He was conscious, and oriented, he was lying in supine position.

Vital Signs:

 Blood pressure (BP): 115/85 taken from the left brachial artery, on sitting position 
Pulse (P): 83 beats per minute (left radial, regular and full in volume).
 Respiratory rate (RR): 18 breath/min
 Saturation” 92%
 Temperature (T): _______0C (________________).
 BMI: Is not calculated due to the absence of instrument to measure weight and height.

H.E.E.N.T

Head: Normal size and shape.

No scar
Normal hair distribution

Eyes: No Corneal ulcer.

Pink Conjunctiva
Normal eyebrows
No peri-orbital edema
No ptosis
No exophthalmoses or strabismus.
The pupils are dilated and are equal in size.

Ears: No tragus or anti tragus tenderness no ear discharge

Nose: no nasal discharge no sines
tenderness

Mouth and throat: no trout infection dental carries and has pink mucosa

Lymphatic and glandular system

There are no significantly enlarged lymph nodes in all accessible areas.

The thyroid gland is also not enlarged.

Respiratory System:

Inspection: There is no cyanosis or clubbing of the fingers.

No Pallor of the skin, conjunctiva, and mucous membranes is observed.
No chest deformity
No visible scar

Palpation: The trachea is centrally located.

No chest lag.
Tactile fremitus is comparable.
Normal chest expansion

Percussion: hyper resonant all over the lung field .

Auscultation: Breath sounds are vesicular.

There was defuse wheeze during exhalation.
No added sound is appreciated.

Cardiovascular system:

Arteries: The pulse volume is normal, the rhythm is regular and there was no abnormal character
or unusual condition of vessel wall.

Veins: The jvp was 2cm above the angle of Louis.

There are no distended veins over the neck, chest wall, no varies, or phlebitis in the legs.

Pericardium (heart):

Inspection:quite pericardium
(no precordial bulge) apical impulse was not visible.
.
Palpation: There is a no parasternal or apical heave. There is also no thrill
anywhere.
 Pmi was palpable at 5th intercostal space MCL

Auscultation: Both heart sounds are normal in intensity over each valvular area.
No added sound is heard. There is also no murmur.

Gastrointestinal system

Inspection: The abdomen is FULL, symmetrical and moves with respiration.

There is localized swelling on right lower quadrant.

There is not flank
fullness, No dilated veins,
No visible pulsation or
peristalsis no visible
masses scar or strea.
The umbilicus is inverted.
Hernia sites are free.

Auscultation: The bowel sound is normoactive.

There is no bruit or friction rub.

Palpation:
• Superficial palpation: No superficially palpable mass.
There was also no tenderness upon such palpation (no change in facial expression).
• Deep palpation: nodeep seated mass or organomegaly

Percussion: No signs of abdominal fluid collection (No shifting dullness or fluid thrill).

Genitourinary system:

There is no costo-vertebral angle tenderness (no change on facial expression) or mass. The kidneys
are not palpable.
Integumentary system:

The skin is not dry and warm. Normal hair distribution. There is no abnormal nail change.

Musculoskeletal system:
The joints are normal and there is no bony deformity.

Nervous system:

Mental Status: The patient is conscious, with a GCS of 15/15.

He is Oriented to place and people around him
His memory is good; He was remembering and answering most of questions when he was asked.
He speaks well.
He has no any hallucinations or delusions.

Cranial Nerves: intact

9. Summary of problems:
Subjective
 Mola beyene is a 40-years-old known asthma, patient for the past 10 years ICS. He presented with
sob of 3 hrs duration associated with that he had chest tightness whitish sputum and wheeze.pt a
sno hx of icu admission or intubation and he has 6 addmisions in the past 10 years 2 admisions in
the past 6 monthes including this one.

Objective
Signs of bronchial asthma
10. Assessment
Acute exacerbation of bronchial asthma precipitated by pneumonia