75 year old female patient presented with fever since 2 days and sob since 4 days

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 


CHEIF COMPLAINTS.


Patient came with cheif complaints of fever since 2 days , shortness of breath since 4 days ,burning micturation since 4 days 


HOPI


 patient was apparently asymptomatic 4 days  back then she developed Shortness of breath since 4 days which was insidious in onset, gradually progressive( from grade 3 to 4) aggrevated on exposure to cold/early morning and relieved on medications

Patient also complains burning micturation not associated with any urgency, frequency/hesitancy 

Complaints of fever since 2 days, associated with chills and rigors ,insidious in onset ,high grade no aggrevating factors, and relieved on medications 

No c/o chest pain ,orthopnea ,pnd

B/l pitting type of edema.  Extending upto knee


PAST HISTORY 


patient is k/c/o HTN since 12 years and is on medication TAB.MET XL 50 PO/BD

K/C/O  BRONCHIAL ASTHMA since 12 years and is medication


PERSONAL HISTORY 


Appetite: normal 

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient have past habit of taking tobacco snuff


FAMILY HISTORY:


no history of similar complaints within the family


GENERAL EXAMINATION 


Patient is conscious, coherent and cooperative

Well built and we'll nourished

Pallor: absent 

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: present ( B/L pedal edema upto knee region)

 





VITALS:

Temp - 97.5 F

BP 120/80 mmhg

Heart rate 120 bpm

Resp Rate 32/min

Sp02 96%

Grbs 169 mg/ dl


RS 

BAE+ 

NVBS+ ,no crepts

no added sounds


CVS 

S1 S2 heard

 no murmurs


P/A 

soft , tenderness present on suprapubic area,no organomegaly,


CNS 



Higher mental functions intact 

No focal neurological deficit 


PROVISIONAL DIAGNOSIS 

?Acute exacerbation of bronchial asthma, 

?CAP

?Sepsis secondary to UTI( dengue Igm +)

?Pre renal kidney injury on CKD ( STAGE V)


INVESTIGATIONS 












Popular posts from this blog

NITHIN CHAKRAVARTHY THESIS

  THESIS   ARTHROPATHY IN TRUNCAL OBESITY PATIENTS AND ASSOCIATED COMORBIDITIES AND THIER OUTCOMES  NEED FOR STUDY AND INTRODUCTION :- The association between OA and T2DM has been traditionally attributed to underlying shared risk factors of age and obesity. Emerging evidence suggests that alterations in lipid metabolism and hyperglycemia might have a direct impact on cartilage health and subchondral bone that contribute to the development and/or progression of OA.(ref 1) While the above association is well studied and documented, patients with trunKal obesity and osteoarthritis are likely to have their illness outcomes considerably influenced by other comorbidities that are likely to affect their outcomes. This has not been studied earlier as per our review of literature and hence the need for this study INTRODUCTION :-     There is increased susceptibility to develop arthritis in those with T2DM, which is supported by observations of higher prevalence of arthritis in those with T2DM
Read more

CME CASE 1

Image
40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS  ** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified  health data shared, AFTER taking his/her/guardian's signed informed consent. Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, i
Read more

THESIS MODEL CASE

Image
 Note - This is an a online e log book to discuss our patient's 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 centred 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. Case sheet: Chief Complaints: A 65yr old male, resident of NALGONDA, labourer by occupation came to OPD with chief complaints of  pain,tingling in the back of left thigh since one month  pain in the l
Read more