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 the comment box is welcome.
Unit 5 admission
A 70 year old female patient came with the c/o fever since 1 week and cough since 1 year (on and off).
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic till 1 week back then Patient developed high grade fever associated with chills and rigors associated with nausea, c/o productive cough since 10 days a/w SOB grade 4, mouth breathing +
Dry cough since 1 year
H/o vomiting a/w giddiness - 2 episodes 10 days back, now subsided
C/o burning micturition since 2 days
C/o polyuria since 2 days
C/o biomass exposure since child hood daily
H/o on and off SoB since 10 to 15 years,using RMP medication
HISTORY OF PAST ILLNESS:
No giddiness f/b vomiting- 3 episodes since 1 year, no H/o seizures
Not a k/c/oDM,HTN,CAD,CVA,TB
PERSONAL HISTORY:
Occupation: house wife
Appetite: lost
Diet: Mixed
Bowel and bladder movements: Regular
Allergies: None
Habits: None
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Patient is consious, coherent, cooperative
Vitals:
Temperature : afebrile
RR: 14 cpm
Bp: 120/80
HR: 105 bpm
Spo2: 100
GRBS: 131 mg%
No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
SYSTEMIC EXAMINATION:
RS: BAE+, Diffuse Wheeze, crepts +
CVS: s1 and s2 heard
P/A: soft, non tender.
CNS: NAD
INVESTIGATIONS:
CBP:
HB:12.3
TLC: 10300
PL: 2.71
CUE:
Albumin and sugars: nil
EC:
PC:
LFT:
TB: 0.83
DB: 0.20
ALB: 3.8
ALT: 25
ALP: 202
AST: 50
RFT:
UREA: 21
SR. CR: 0.8
UA: 2.0
Na: 141
K: 3.6
Cl: 91
Serology: negative
ABG:
Ph: 7.443
Pco2: 37.4
Po2: 79.9
So2: 94.5
Hco3(p.st): 25.9
Hco3 pc: 25.2
PROVISIONAL DIAGNOSIS:
Excarcerbation of COPD
? Viral pneumonia
