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.
This the case of 75 years old female housewife , resident of miryalaguda
CHEIF COMPLAINTS:
Shortness of Breath Since 10days
Dry Cough Occasionally.
HISTORY OF PRESENTING ILLNESS: Patient was apparentley asymptomatic 10 days ago then she developed a shortness of breath which is insidious in onset,MMRC Grade 2 not associated with Wheeze.Aggrevated on exposure to cold and dust.Orthopnea(+). No paroxysmal nocturnal dyspnea. Patient also has a chief complaints of dry cough since 1week occasionally . No history of fever
No history of chest pain
No history of chest tightness
No history of heamoptysis,swelling &palpitations.
No chief complaints of loss of weight & loss of appetite .
HISTORY OF PAST ILLNESS :
History of similar complaints since 10years on rotex inhaler (FLUTICAZONE &VILANTROL).
Patient on tablet ACEBROPHYLLIN 100mg /po/bd
Known case of Asthama since 10yrs
Known case of Diabetes since 5 days.
N/k/c/o Tuberculosis ,Hypertension ,Epilepsy ,thyroid disorders .
TREATMENT HISTORY :
Diabetes since 5 days but not on medication.
Asthama on inhaler usage.
PERSONAL HISTORY :
Married , appetite normal
mixed diet,
bowel & bladder movements are regular .
No known allergies
No addictions.
FAMILY HISTORY:
No significant.
MENSTRUAL HISTORY:
Age of menarch: 14 years
Age of menopause: 49 years
GENERAL EXAMINATION:
No pallor ,icterus clubbing ,cyanosis ,lymphadenopathy
There is Bilateral pitting edema up to ankle.
Temperature: afebrile, Pulse:110bpm
Respiratory rate: 25cpm
BP: 140/80mmofhg, Spo2: 96% GRBS :358mg%
SYSTEMIC EXAMINATION:
Cardiovascular system: S1S2 heard, no thrills ,no murmurs.
Respiratory system:
Inspection:
Shape of chest:Barrel shaped
Teachea is central
Bilateral symmetrical chest expansion observed
Bilateral course crests,diffuse (+)
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.
Abdomen:
Shape: scaphoid
Tenderness:no
No palpable mass
No free fluids,no bruits
Liver&Spleen not palpable
Bowel sounds: yes
Central nervous system: Intact .
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
Comments
Post a Comment