General medicine e-log

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Chief complaints:

A 35 year old male came with complaints of 

• fever since 5 days
• cough since 2 days 
• breathlessness since 1 day

HOPI:

Pt was apparently assymptomatic 5 days back then developed fever which was high grade,intermittent, and associated with chills, relieved on taking medication not associated with vomitings, burning micturition, loose stools.

Two days later patient complained of cough  with bloody expectoration and shortness of breath (grade II),aggrevated on lying down and relieved in sitting position.For which he was admitted to a private hospital 1 day back and as the symptoms aggravated he was shifted to our hospital. Presently patient complaints of SOB (grade IV) and cough.

PAST HISTORY: Not a k/c/o DM,htn,tb,asthma,epilepsy 

Personal history:

Occupation:daily wage labourer 

mixed diet 

Appetite reduced

Bowel n bladder movements regular 

Sleep adequate 

Addictions: 

Consumes Alcohol since 15 years, stopped 5 years back on his own will and then started 2 months back, consumes 2 bottles/day (country liquor)

Last consumed 6 days back 1 quater

Consumes khaini (chewable tobacco) since 15 years everyday 2 packs

Last consumed 3 days back 1 packet

Family history:

Not significant 

CLINICAL IMAGES:

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative 

Moderately built and nourished.

No anaemia,no icterus,no cyanosis,no clubbing,no lymphadenopathy 

On admission:

BP:140/80mmhg

PR:66bpm

RR:46cpm

SPO2: 67% on RA

GRBS: 94mg/dl

SYSTEMIC EXAMINATION:

CVS: S1,S2, +

RS: B/L diffuse crepts, air entry decreased in right lower lobe 

P/A:Soft, Non tender

CNS: NAD

PROVISIONAL DIAGNOSIS: 

COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA ?ARDS.

INVESTIGATIONS:

Day 1: ABG at 6:30pm

Day 1: ABG at 11:00pm

Day 2: ABG  at 6:00am

Day 3

S: Pt on O2 of 10ltrs and intermittent CPAP

Complaints of BACK PAIN 

Fever spikes present

O:

VITALS: 

BP: 130/80mmhg 

PR: 79bpm 

RR: 22cpm 

Temp: 98.6f 

GRBS: 125mg/dl at 6:00am   

SpO2: 68%

SYSTEMIC EXAMINATION: 

CVS: s1,s2 no added sounds 

P/A: not tender,Soft 

RS: BAE+ B/L DIFFUSE CREPTS

CNS: NAD

A: COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA 

P: 

INJ.Zofer

Inj.Pan

Inj.Lasix

Inj.Neomol  1g/iv sos if temp >101f

Tab.Dolo 650mg RT/TID

nebulisation

Budecort 12 th hrly

Duolin 8 th hrly

 

Day 4

S: SOB decreased 

Fever spikes present

O:

Pt on O2 of 16 ltrs and intermittent CPAP

VITALS: 

BP: 140/70mmhg 

PR: 98bpm 

RR: 18cpm 

Temp: 100.7f    

SpO2: 77% on 16ltrs of O2

On CPAP - PC mode with NIV - Spo2 90% on FiO2 50

SYSTEMIC EXAMINATION: 

CVS: s1,s2 no added sounds 

P/A: not tender,Soft 

RS: BAE+ B/L DIFFUSE CREPTS

CNS: NAD

A: COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA 

P: 

INJ.Zofer 4mg po/bd

Inj.Pan 40mg po/od

Inj.Piptaz 4.5gm iv/tid

Inj.Neomol  1g/iv sos if temp >101f

Tab.Dolo 650mg RT/TID

nebulisation

Budecort 12 th hrly

Duolin 8 th hrly