General medicine case 9
A 60 year old female patient with Repeated cough and SOB
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Case
A 60 year old female patient with Shortness of breath and cough since 5 days.
History of present illness:
Patient was apparently asymptomatic 1 year back before the standing illness.Then the patient was admitted to the Casualty with Shortness of breath and cough since 5 days.
1 year back patient had the similar complaints of shortness of breath and cough for which medications were taken and then was normal.
Patient's daily routine:
Patient wakes up daily by 6 o'clock and does the household work and eats by 10 o'clock and skips lunch usually and takes dinner by 7 o' clock.
No H/o pedal edema
- No H/o decreased urine output
-No H/o heamaturia
- No H/o loss of appetite
-H/o weight loss.
Past history
She gave long history of usage of bio fuel since childhood and still uses it now She is diagnosed to be diabetic 4 yrs back ( on medication since 4 yrs)
No history of HTN/DM/Epilepsy/TB/Thyroid disorders
The patient had undergone tubectomy at middle age.
Personal history
Diet : mixed
Appetite : decreased
Bowel and bladder : regular
Sleep : normal
No addictions
Family history
No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders
No similar complaints in the family.
Treatment history
Not significant.
General examination
Patient is conscious, coherent and cooperative.
Malnutrition+ve,mild dehydration.
Pt had pallor,
no icterus,no cyanosis,no clubbing,no lymphadenopathy.
Vitals
Temperature:98.7'F
Bp :110/70 mm hg
Pulse rate:60/min
Respiratory rate:18/min
Spo2: 98%
Systemic examination:
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Auscutation:
Normal with regular heartbeat
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Dyspnoea+ve
Wheezing+ve
BAE present decreased in rt side
PER ABDOMEN:
No tenderness.
No palpable mass.
Bowel sounds+ve
Shape of abdomen:scaphoid
No organomegaly
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
Reflexes: present
Provisional diagnosis:
CHRONIC BRONCHITIS
ACUTE EXACERBATION of COPD
Investigations:
Colour Doppler 2D ECHO:
27/10/21
Final diagnosis:
CHRONIC BRONCHITIS
ACUTE EXACERBATION of COPD
Treatment plan:
27/10/21
Spo2,PR,BP monitoring 4 th hrly
Head end elevation
02 inhalation to maintain PR 92-93%
Fever charting 4th hrly
Inj. Augmentin 1.2g/iv/bd
Tab. Azithromycin 500 mg/PO/OD
Tab.pcm 650 mg/po/bd
Inj. Pan 40 mg/iv/od
BP, PR charting 4 th hrly
GRBS charting 6 th hrly
28/10/21
Inj. Augmentin 1.2g/iv/bd
Tab. Azithromycin 500 mg/PO/OD
Tab.pcm 650 mg/po/bd
Inj. Pan 40 mg/iv/od
NEB Budicort 8 th hrly
29/10/21
Inj. Augmentin 1.2g/iv/bd
Syp. Ascoryl 10 ml tid
Tab. Azithromycin 500 mg/PO/OD
Tab.pcm 650 mg/po/bd
Inj. Pan 40 mg/iv/od
BP, PR charting 4 th hrly
GRBS charting 6 th hrly
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