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




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