blog 4

Date:22/11/22
This is an online E- log book to discuss our patient's de- identified health data shared informed 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. This E- log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

CHEIF COMPLAINT :

A 60 year old female patient came to the  OPD with  chief complaints of chest pain, difficulty in breathing since 3 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 days  back  and then she noticed  with shortness of breath,which progressed from grade 3 to grade 4 over 3 days. 
Orthopnea is noticed
No cough 
No fever
No vomiting
No loose stools
No pedal edema


PAST HISTORY: 
Patient is diabetic since 5 years and hypertension since 10 years
No CAD, asthma, TB, epilepsy, thyroid disorders. 
No history of any surgeries in the past. 

PERSONAL HISTORY:

Appetite: normal 

Diet: mixed 

Sleep: adequate 

Bowel and bladder movements: regular 

Micturition: normal 

Addictions: no

FAMILY HISTORY:
There is no history of similar complaints in the family.


TREATMENT HISTORY:
 Patient is on regular medication for Diabetes since 5 years Tab. MT. GLIMI M3 BD. 
Hypertension since 10 years 
Tab. PROLOMET AM 
She is not allergic to any known drugs. 


GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person. 
There is no signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy and edema.


VITALS:
Temperature: Afebrile

Blood pressure: 160/60mm/Hg

Pulse rate:  50 bpm

Respiratory rate: 28/min

SPO2: 91% At room temperature 

GRBS : 323mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:
No thrills 

S1 and S2 sounds are heard 
No cardiac murmurs

RESPIRATORY SYSTEM:
Dyspnoea-  yes

wheezing sounds - yes

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- Distended

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver - not palpable

Spleen- not palpable

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious 

Speech: normal 

Signs of meningeal irritation
                Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:
 
ECG:

ULTRASOUND :


DIAGNOSES : Heart failure with reduced ejection fraction( moderate left ventricular dysfunction). 

TREATMENT :

1.INJ.LASIX 20mg IV TID
2.TAB.AMLONG 5mg
3.GRBS 6th hourly
4.Inj.HUMAN ACTRAPID S.C 
5.T.PANTOP 40mg IV
6.BP monitoring 2nd hourly
 SPO2 monitoring 2nd hourly
7.O2 inhalation sop  2lit/min
8.T.ISOLAZINE 20mg PO BD
9.T.ECOSPIRIN - AV 
10.INTERMITENT NIV. support
11.Strict IPO charting 
12.INJ.MONOCEF 1gm IV BD
13.TAB.NODOSIS 500mg PO TID
                   DUOLIN
14. Neb.                           }  TID
                   BUDECORT. 
                    

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