80 year old Male with fever and SOB

 I am Soumya 5th semester student .


This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them


CHEIF COMPLAINTS


Fever since 2 days

Cold and cough with sputum since 2 days

SOB since 2 days



HISTORY OF PRESENT ILLNESS

Apparently normal 3 days back 

Then had fever , intermittent type since 2 days

Then went to nearby hospital and got treatment, went home

Next day had other fever episode and aggregating SOB ,then came to KIMS 


HISTORY OF PAST ILLNESS

Not significant 

TREATMENT HISTORY

Nil

FAMILY HISTORY

Not significant


PERSONAL HISTORY 


Mixed diet

Appetite normal

Micturition normal

Bowel movements regular

No known allergies 

Alcohol: Daily whiskey and if not kallu since more than 50 years

Smoking bidi  Daily about 1 pack/day (20 in each pack) since more than 50 years


GENERAL EXAMINATION 

O/E

Pallor: mild

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Oedema of feet:  no

      Vitals:

PR :120 bpm

Temp : 103 F 

RR : 36 cpm

BP : 160/90 mmHg

Spo2 : 88 at room air at 6 lit of O2

GRBS : 195

SYSTEMIC EXAMINATION

RS :BAE present,NVBS

CVS:S1 S2 present

CNS:NAD

PA : soft ,non tender 


PROVISINAL DIAGNOSIS

AE COPD WITH VIRAL PNEUMONIA 


INVESTIGATIONS

31/8
















1/9
















DIAGNOSIS


Acute excerbation of COPD WITH

??viral pneumonia 

 
TREATMENT


1.IV FLUIDS NS with 2 amp KCL
2.Inj.AGUMENTIN 1.2gm IV/TID
3.Inj.PAN 40 mg IV /OD
4.Inj.OPTINEURON 1 amp in 100 ml NS IV/OD
5.Tab.DOLO 650 mg /QID
6.Inj. NEOMOL 1 gm IV/SOS ( if temp >101F)
7.Tab.PULMOCLEAR BD
8.Tab.MONTAIR LC OD
9.Syp ASCORIL LS 10 ml /TID
10.NB with DUOLIN BUDECORT  8th hourly
11. Monitoring vitals

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