gm prefinal
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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
