50 Y/M with SOB
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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.
Chief complains: Fever 4 days back ,Cough since 1 day,SOB since 1 day
HOPI:
Patient was apparently asymptomatic 2 years ago then he developed neck pain so he went to local hospital and diagnosed with htn and had been using telma beta 50mg since then and he uses medicine regularly.
He was asymptomatic 7 days ago and he developed low grade fever associated with chills and rigors so he went for consultant and he got an injection so fever subsided; after that he developed generalised weakness for which he diagnosed with typhoid and got treated .after 4 days he tested positive for dengue . fever subsided after medication and he developed dry cough on 23 /08/22 night and brought to our hospital for further management
Past History : Not a known case of Diabetes, Asthma , CAD, Epilepsy
Known case of HTN since 2 years and was on regular medication .
Personal History :
Diet : mixed
Appetite: normal
Sleep: adequate
Micturition : normal
Bowel: regular
Addiction: Alcoholic since 15 years ( stopped now ) , Bidi sice 15 years ( now ocassionally )
Family History :
Wife is a known case of HTN
General Examination:
Patient is conscious , coherent and cooperative
He moderately built and nourished.
No Pallor ,No icterus ,No cyanosis ,No clubbing No lymphandenopathy ,No edema
Vitals: Temp-Afebrile
PR: 104bpm
RR: 38 cpm
BP: 130/100 mmHg
SYSTEMIC EXAMINATION:
Respiratory system:
Trachea : central
Breath sounds: vesicular
Wheeze present
Dyspnea : present
Cvs: S1,S2 heard no cardiac murmurs
CNS: no focal neurological deficits
P/A:soft non tender
Plan of Care :
- IV fluid NS 10mL
Z- Inj. Monocef 1gm IV/BD
- Inj. Pan 40mg IV/OD
- Inj. Neomol 1gm IV/SOS ( if temp.more than 101F)
- Tab. Dolo 650mg TID
- Tab. Doxy 100mg PO/BD
- Nebulization with Duolin and Budecort 8th hourly
- GRBS monitoring 6th hourly
- Monotor Vitals
Provisinal Diagnosis :
Viral Pneumonia with severe ARDS
Acute viral hepatitis??
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