60 F with SOB since 2 months

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NOTE: 


The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 


Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.


This E-log also reflects my patient's centered online learning portfolio.




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 a diagnosis and providing treatment best to our skills and wisdom. 

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Patient is a 60 year old housewife, resident of narketpally 

Chief complaint: 

Shortness of breath since 2 months
Chest pain 10 bays back

HOPI : 

Patient was apparently asymptomatic 2 months ago when she developed shortness of breath which was insidious in onset, intermittent in nature. It was exacerbated with activity (grade 1 mmrc) and relieved by taking rest and taking medication :  cetirizine and rotahaler fluticasone. 

Acute exacerbation since 3 to 4 days of sob grade 2 mmrc relieved by taking medication. Associated with dry cough which is increased at night associated with sore throat since 2 days which was relieved on medication. Aggrevated by cold weather. not associated with fever. not associated with sneezing. 

PAST HISTORY : 

She was diagnosed with type 2 diabetes mellitus on admission. Not a k/c/o 
HTN, TB, Epilepsy, thyroid disorders. 

FAMILY HISTORY: Elder sister : k/c/o Asthma since early childhood. 

PERSONAL HISTORY 

Diet : Mixed 
Appetite: Normal 
Bowel & Bladder: regular 
Sleep : Adequate 

Addictions : 

• none 

TREATMENT HISTORY : 

Usage of tab. C

GENERAL EXAMINATION 

Patient is c/c/c well oriented to time, place and person. 

Moderately built and nourished. 

Pallor & Icterus were seen 

No Cyanosis, Clubbing, Lymphadenopathy. 

 VITALS 

Temperature - Afebrile
Pulse rate - 100 bpm
Respiratory rate - 25 cpm
BP - 140/80 mmHg
SpO2 - 96% at room temperature
GRBS - 350 mg/dL
















SYSTEMIC EXAMINATION

1) Respiratory System

Inspection :
Shape of chest - barrel shaped
Trachea is central
Bilateral symmetrical chest expansion observed
Apical impulse 
No visible pulsations/sinuses/scars seen

Palpation : (Confirming findings on inspection)
Trachea - central
Apex beat - normal
Respiratory movements - normal
Vocal fremitus - normal
No tenderness over intercostal spaces

Percussion : 
Resonant note heard bilaterally

Auscultation:
Vesicular breath sounds are heard.


2) CVS - S1, S2 heard ; no murmurs or thrills heard 

3) Abdomen - Scaphoid abdomen, no tenderness, no palpable mass, normal hernial orifices, no free fluid, no bruits
No palpable spleen or liver

4) CNS - All higher mental functions, cranial nerves, motor system and sensory system are intact. 
Normal speech observed.


INVESTIGATIONS : 

Urinalysis 
2D Echo 

Culture & Sensitivity 

Hemogram 


TREATMENT HISTORY: 

DAY 1 : 
Inj. Augmentin 1.2gm BD
Inj. Heparin 5000 IU QID
Inj. Lasix 40 mg BD
Inj. Pantop 40 mg BD
Tab ecosprin 75 mg OD
Tab. Clopidogrel 75 mg OD
Tab. Rosuvastatin 120 mg OD
Tab. Mucinac TID
Tab. Montac LC BD
Tab. Prednisolone 40 mg OD
Tab. Azithromycin 500 mg OD
 Duolin budecort BD



Day 2 : 
Inj. Augmentin 1.2gm BD
Inj. Heparin 5000 IU QID
Inj. Lasix 40 mg BD
Inj. Pantop 40 mg BD
Tab ecosprin 75 mg OD
Tab. Clopidogrel 75 mg OD
Tab. Rosuvastatin 120 mg OD
Tab. Mucinac TID
Tab. Montac LC BD
Tab. Prednisolone 40 mg OD
Tab. Azithromycin 500 mg OD
 Duolin budecort BD


Day 3 : 
Inj. Augmentin 1.2gm BD
Inj. Heparin 5000 IU QID
Inj. Lasix 40 mg BD
Inj. Pantop 40 mg BD
Tab ecosprin 75 mg OD
Tab. Clopidogrel 75 mg OD
Tab. Rosuvastatin 120 mg OD
Tab. Mucinac TID
Tab. Montac LC BD
Tab. Prednisolone 40 mg OD
Tab. Azithromycin 500 mg OD
 Duolin budecort BD
















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