GENERAL MEDICINE CASE 9

 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

45 years old female patient came to opd with chief complain of fever and shortness of breath

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 15days back and then she developed fever so she visited local hospital where she found out to be hypertensive and decresed blood count because of this she experiencing generalized weakness and body pains ,then later when she is also experiencing shortness of breath  for which she visited to kamineni.

PAST HISTORY

No history of DM,hypertension

No history of TB

She had to FTND delivery

Regural mensuration cycle

PERSONAL HISTORY

Takes mixed diet

Normal appetite

Adequate sleep

Regular bowel and bladder movements

Not an alcoholic and smoker

FAMILY HISTORY

No similar complains seen in the family members

TREATMENT HISTORY

She is not a know case of any drug allergy

GENERAL EXAMINATION

Patient is conscious ,coherent and cooperative

No pallor

No icterus

No clubbing

No lymphadenopathy

Vitals:

   Temp-103 °f

    Bp-100/80mmHg

   PR-144BPM

   RR-28CPM

   SPO2-97%RA

   GRBS-285mg/DL

SYSTEMIC EXAMINATION

CVS:S1S2+

RS:DYSPNEA GRADE4-GRADE3.

   No wheeze

   Trachea position-central

   Vesicular breath sounds heard

PER ABDOMEN:

Shape-scaphoid

Bowel sounds heard

CNS:NAD

INVESTIGATION


















PROVISIONAL DIAGNOSIS:community acquired pneumonia

TREATMENT
 Head end elevation,IVF 100ml/HR
 O2 inhalation to maintain Spo2 
 INJ.hydrocortisone 100mg IV/OD
 INJ.augmentin 1.2gm IV/BD
 INJ.Oeriphyllin IV/BD
 INJ.neomol 1gm IV/sos
 TAB.DOLO 650mg po/tid
 TAB.ultracet 1/2 po/Qid
TAB.Azitromycin 500mg po/of
 TAB.pantop 40mg po/of
 TEPID SPONGING 



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