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
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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
COLOR DOPPLER 2D ECHO
ECG
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
* TAB.AZITHROMYCIN 500mg/PO/OD
*TAB. PARACETAMOL 650mg/PO/BD
*INJ. PANTOP 40mg/IV/BD
* INJ.HAI /SC/TID
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