This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
A 70 year old female came with c/o SOB since 7 days ( progressed from Grade 2 to grade 3)
HOPI:
SOB Associated with cough with expectoration,scanty sputum present
No h/o pedal edema , decreased urine output, hematuria,frothy urine
Past history:
K/c/o HTN since 5 yrs on medications (T.telma H 40 mg )
Similar complaints in the past since 2 years ? Seasonal variation +
PERSONAL HISTORY
Appetite-decreased
Regular bowel and bladder movements
No addictions
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
Malnutrition+,mild dehydration
No pallor, Icterus, cyanosis, clubbing, lymphadenopathy , edema
VITALS :
Temp: 98.7 F
PR: 60 bpm
BP: 110/70 mm hg
RR: 18 cpm
Spo2 - 98%
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Dyspnoea +
Wheeze +
BAE present decreased in rt side
Expiratory wheeze + on rt IMA,ISR,IAA
B/L Inspiratory crepts + in ISA +,IAA +
PER ABDOMEN: Soft,non tender
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
PROVISIONAL DIAGNOSIS-
? PRE RENAL AKI WITH COPD
Day 1 soap notes :
S : SOB decreased
O : O/E
Pt is C/C/C
Temp : afebrile
BP :
PR :
CVS :S1S2 +
RS : BAE +
Tubular sounds + at rt IMA, ISA
Added sounds at B/L ISA, IMA
P/A : soft , NT
BS +
CNS : : no focal deficit
A : ? PRE RENAL AkI with COPD
P :
1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITH
Duolin- 8 the hourly
BuDicort -17 th hourly
Furacort - 8 th hourly
7. BP charting 8 th hourly
8. I/O charting
Day 2
S : SOB decreased
Fever spike +
O : O/E
Pt is C/C/C
Temp - 100.1F
BP - 90/60 mmHg
PR -76 bpm
CVS :S1S2+
RS : BAE +
RT tubular sounds at IMA, ISA
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly
Furacort - 8 th hourly
7. BP charting 8 th hourly
8. I/O charting
Plan for discharge
Day 3
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 100/70 mmHg
PR -74 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly
Furacort - 8 th hourly
7. BP charting 8 th hourly
8. I/O charting
Day 4
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 110/70 mmHg
PR -64 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly
Furacort - 8 th hourly
7. BP charting 8 th hourly
8. I/O charting
Day 5
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 110/60mmHg
PR -64 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI (resolved ),Acute exacerbation of COPD, Anemia
P 1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly
Furacort - 8 th hourly
7. BP charting 8 th hourly
8. I/O charting
Plan for discharge
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