gm prefinal

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A 70 year old female patient came with the chief complaint of shortness of breath since  evening

History of present illness :-  patient was apparently asymptomatic  4 Days back and had a episode of dyspnea (grade 4).
She was bought to the OPD on 7/12/22 evening. Her bp was 220/120mm Hg and her CGS was falling down.she is also assosiated with fever, dry cough, throat pain, chestpain, constipation

History of past illness :- k/c/o hypertension since 6 yrs and on irregular medication 
N/k/c/o DM , asthma, epilepsy, tuberculosis, Lymphadenopathy 
 
Personal history :- 
 Diet :- mixed 
Apetite :- reduced 
Sleep :- adequate
Bowel and bladder movements :- irregular 
Addictions :- smoking ,alcohol
Allergies :- No

Family history :- no history similar complaints in the family 

GENERAL EXAMINATION :- 
patient is conscious, non coherent, 
Weakly built, malnourished 
No pallor, cyanosis, icterus
No clubbing of fingers 
No lymphadenopathy 
No Pedal edema 

Vitals :- 
Temp - febrile 
Pulse rate :- 84bpm 
Res. Rate :- BAE +
Fine crepts + infraaxillary 
     Wheeze + infraaxillary 
Bp :- 130/70mmhg
CVS :- S1S2 + 
CNS :- NAD 
Grbs :- 140 mg/dl

SYSTEMIC EXAMINATION :- 

CNS EXAMINATION :-
Patient is concious, non coherent, non coperative 
Cranial nerves :- intact 

CVS EXAMINATION :- 
S1S2 heard 
NO murmurs 

RESPIRATORY EXAMINATION :- 

INSPECTION :- kyphoscoliosis 
No pulsations 

PALPATION :-  Trachea in deviated towards left position 

PERCUSSION :- supra clavicular and infra clavicular,infra axillary dull sounds heard

AUSCULTATION :- crepts and wheeze sounds are heard in infraaxillary region 

ABDOMEN EXAMINATION :- 
Shape of the abdomen :- scaphoid 
Tenderness :- No 
Free fluid :- No 
Liver :- not palpable 
Spleen :- not palpable 


PROVISIONAL DIAGNOSIS :- ?COPD ?Type 2 respiratory failure

INVESTIGATIONS :- 
ABG :- 


HEMOGRAM :- 


Chest x -ray :- 



ECG :- 

Treatment :- 
1. INJ PANTOP - 400 mg  (IV) - OD

2. INJ  AUGUMENTIN - 2gm (IV) -TID

3.INJ OPTINEURON - 1 ample 

4.HYDROCORT - 100 mg - BD

5.TAB DOLO - 650 mg 

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