MEDICINE CASE DISCUSSION


60 year old female patient  with shortness of breath & cough with expectoration.



October 28 , 2021


Name :- P.Manasa

9th Semester

Roll no :- 102


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

CASE :-

  A 60 year old lady resident of Suryapet is a farmer     by occupation was brought to the causality    (on 27th October 2021) with cheif complaints of


            1) Shortness of breath since 3 days.


HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 10 years back then she had an episode of SOB with cough with expectoration and was taken to hospital relieved after 2-3 days.

 She had intermittent  episode of acute expectoration yearly twice or thrice for which she has to be hospitalized.


HISTORY OF PAST ILLNESS :-

She had history of similar complaints 6months back for which treatment taken.

She gave a long history of usage of BIOFUEL since childhood and still uses.

She had a history of DIABETES MELLITUS since 5yrs , taking medications.

She had history of ASTHMA since 15yes back

No history of Hypertension , Epilepsy,  Cardiovascular diseases etc ..


PERSONAL HISTORY :-

          DIET -  MIXED

          APPETITE -   NORMAL

          REDUCED FREQUENCY OF PASSING STOOLS

          MICTURATION  -Regular

          SLEEP -   ADEQUATE

          ADDICTIONS -  OCCASIONALLY ALCOHOLIC

          NO H/O DRUG ALLERGIES.


FAMILY HISTORY :-


No history of similar complaints in the family


GENERAL EXAMINATION

Patient was conscious, coherent & co-operative.

     * Moderately built & Moderately nourished.

    

  Pallor - present

No signs of clubbing , cyanosis , lymphadenopathy , pedal oedema.



VITALS :-


TEMPERATURE :-  98.4 F

PULSE RATE :-   110 bpm

RESPIRATORY RATE:-  30cpm

BLOOD PRESSURE :- 130/80 mm Hg

SPO2:- 90% at room temperature



SYSTEMIC EXAMINATION


Cardiovascular System:-

S1, S2 heart sounds are heard

No murmurs , Thrills.


Respiratory System

Normal vesicular breath sounds are heard

Dyspnea - present

Wheeze - present

Crepitations are present in all lung fields.


Abdomen


Soft , nontender 

No organomegaly


CNS

No Neurological deficits are seen

No signs of meningial irritation


PROVISIONAL DIAGNOSIS

CHRONIC BRONCHITIS (AECOPD)


INVESTIGATIONS

HEMOGRAM





CUE







Color - Yellow

Appearance - clear

Pus cells - 3-4

Albumin - +++


Sugar - Nil


SERUM ELECTROLYTES




Sodium - 137meq/L

Chlorine -  96meq/L


Random Blood Sugar - 258mg/dl


LIVER FUNCTION TEST


RFT


Serum creatinine- 0.9mg/dl

Urea -  60mg/dl


ABG




USG

Impression :- Moderate Hepatomegaly                       with Grade -1 FattyLiver

COLOR DOPPLER  2D ECHO


ECG




27/10/21


29/10/21


TREATMENT


On 27/10/2021


*NEB with BUDECORT 8th hrly

 *NEB with IPRAVENT 6th hrly

*Spo2 /PR/BP monitoring 4th hrly

* Head end elevation

*O2 inhalation

*Fever charting 4th hrly

*I/O charting 24hrly

*SYP .ASCOYTO 10ml /po/TID

* INJ.AUGMENTIN 1.2g/IV/BD

* TAB.AZITHROMYCIN 500mg/PO/OD

*TAB. PARACETAMOL 650mg/PO/BD

*INJ. PANTOP 40mg/IV/BD

*GRBS CHARTING 6th hrly

* INJ.HAI /SC/TID


On 28/10/2021


*NEB with BUDECORT 8th hrly

 *NEB with IPRAVENT 6th hrly

* INJ.AUGMENTIN 1.2g/IV/BD

* TAB.AZITHROMYCIN 500mg/PO/OD

*TAB. PARACETAMOL 650mg/PO/BD

*INJ. PANTOP 40mg/IV/BD

* INJ.HAI /SC/TID




 







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