This is an online E log book to discuss our patient's de-identified health data shared 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 the comment 

CASE PRESENTATION:

55year old male agricultural labour

pt was apparently asymptomatic 15years ago,when he developed productive cough(increased on lying down) associated with sob grade 2-3, insidious onset,gradually progressive since 10years

c/o pedal edema since 2months and decreased urine output since 1month

abdominal distension since 2months,no fever,wt loss,appetite decreased

burning micturation since 2months,

no chest pain, palpitations, sweating

h/o giddiness on and off, decreased sleep

c/o constipation since 2months


alcoholic since 20years,stopped 10years ago

smoker stopped 10years ago

used ATT for 6 months,3 months ago

uses inhalers on and off since 10years


not a k/c/o DM,HTN,CAD,CVA,Epilepsy 


GENERAL EXAMINATION:

Pt was conscious,coherent,cooperative 

Clubbing +

Pitting type of pedal edema +
No pallor,Cyanosis,icterus,lymphadenopathy,

VITALS:

Afebrile 

Bp:120/80mmhg

Pr:68bpm

Grbs:106mg/dl

at the time of presentation spo2:79%

neb duolin,budecort given

o2inhalation...spo2 is 95% with 4lits o2

SYSTEMIC EXAMINATION:

RS:

Barrel shaped chest 

AP DIAMETER:26cm

TRANSVERSE DIAMETER:25cm



BAE+,B/L coarse crepts+

CVS:S1 AND S2 HEARD 

NO MURMURS OR ADDITIONAL SOUNDS 

CNS: HMF INTACT 

SENSORY,MOTOR SYSTEMS INTACT

CRANIAL NERVES FUNCTION INTACT

P/A:SOFT,NON TENDER,BOWEL SOUNDS +


INVESTIGATIONS:

CXR PA VIEW :



HRCT CHEST:

TRAM TRACK APPEARANCE



SIGNET RING APPEARANCE 




USG ABDOMEN:
ABG:


 DIAGNOSIS:

1- acute exacerbation of copd /bronchiectasis

2-h/O of tuberculosis 

 3- corpulmonale

CHARTING:


TREATMENT:

DAY1:

1. O2inhalation 4l

2.Neb.DUOLIN 4TH HRLY

3.Neb.BUDECORT 12TH HRLY

4.Inj.HYDROCORTISONE 100MG /IV/SOS

5.SPO2 MONITORING 

6.BP/PR/I/O MONITORING 


DAY2:





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