CBBLE UDHC SIMILAR CASES This is an 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 patient's clinical problems with collective current best evidence based inputs.

PULMONOLOGY BLOG

RICU admission 
Bed 3 
68 y old male , Pt came with the chief complaints of breathlessness since 4 months, Rt sided chest pain since 5days

HOPI : 
Pt was apparently asymptomatic 4yrs back then developed breathlessness which was insidious in onset, gradually progressed from MMRC grade I to grade II. 
Breathlessness aggrevated during exertion and relieved on taking rest. No positional variation , not associated with wheeze, orthopnea present.
Pt c/o Rt sided chest pain since 5 days, insidious in onset, dragging type of pain , non radiating.
No c/o cough , chest pain, chest tightness,  haemoptysis. No fever spikes. 

PAST HISTORY: 
H/O Similar Complaints in the Past 2yrs back and started using inhaler since 2yrs.
Past H/O TB 20yrs back, used ATT for 6 months
N/K/C/O  DM, HTN, CAD, EPILEPSY. 

PERSONAL HISTORY: 
Diet : normal 
Appetite : normal 
Bowel and bladder movements : normal
No known allergies 
Chronic smoker for 20 years - 1 beedi pack/ day
Stopped since 10years

FAMILY HISTORY-  Not significant

O/E : Patient is C/C/C 
Pallor - 
Icterus  -
Cyanosis - 
Edema of feet - 
Lymphadenopathy  - 
Clubbing -

VITALS :  
Temp :  Afebrile 
PR : 105bpm
BP : 160/100 mmhg 
RR : 32cpm 
SPO2 : 82 % at RA 
GRBS: 94mg%


SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : BAE + , VBS + , B/L crepts + in Lt. side SSA, ICA, MA, ISA, INTER SA.

CNS : NAD 

PA :  soft, non tender 
INVESTIGATIONS-

  DIAGNOSIS- ACUTE EXACERBATION OF COPD WITH GRADE 1 RESPIRATORY FAILURE

TREATMENT GIVEN-
O2 inhalation with 2-4lts O2 to maintain spo2>94%
Nebulization- Duolin-TID, Budecort- BD, Mucomist-TID
Tab. Seldenefil 20mg BD
Inj. Hydrocort 100mg IV OD
Tab. Cefixime 200mg PO BD
Tab. Pan 40mg OD PO BBF
Tab. Diclofenac 50mg PO OD
Tab MVT PO OD




Popular posts from this blog

PARAPERISIS-1

Image
"I've been given this case   https://srianugna.blogspot.com/2020/05/hello-everyone.html l https://youtu.be/3VVH7w3rWSM  to solve in an attempt to understand the topic of "paraparesis." This may develop my competency in a) reading and comprehending clinical data related to "paraparesis" including history, clinical findings, investigations b) come up with a diagnosis such as: 1) Anatomical location of the root cause 2) Physiological functional disability 3) Biochemical abnormalities that could be a root cause at a molecular level 4) Pathology that could reflect the root cause at a cellular level c) a treatment plan for each of these patients of paraparesis that can have a pharmacological and non pharmacological component. d) learning the scientific basis of diagnostic and therapeutic approach in terms of past collective experiences and experiments (aka evidence based medicine). Following is my analysis of patient's problem. Patient is 18 year old came wit
Read more

25 year old male patient with alcohol dependence syndrome

Image
A 25 year old male , daily labour by occupation ,came to the OPD with cheif complaints of - Head injury since seven days  associated with vomitings, complains of tremors since 2days History of presenting illness - patient was apparently asymptomatic 7 days  back then he had head injury (under the influence of alcohol) associated with vomiting since 7days back -1 episode/day projectile,contents-food , tremors developed after stopping alcohol consumption from 2 days Past history -  Pateint ia an alcoholic since 1 year which was consumed occassionally then he increased consumption since 3 months because of personal family issues then stopped alcohol consuption from 4 days  not a known case of htn , dm ,  epilepsy , asthma , tb no previous surgical history  no history of gallstones in the past Personal history : Diet - mixed ,appetite -decrease appetite ,bowel movement - regular,  bladder movements - regular  , addictions(alcohol) -  alcoholics in 1 year takes at least 750ml occasional con
Read more