A 65 YEAR OLD FEMALE WITH FEVER AND DYSPNOEA

This is 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 patients 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

CHIEF COMPLAINTS

 C/O FEVER SINCE 10 DAYS

C/O SOB SINCE 5 DAYS

  

HISTORY OF PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK THEN SHE DEVELOPED FEVER OF HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS. CONTINUOUS, RELIEVED WITH MEDICATION, DIURNAL VARIATION PRESENT MORE DURING THE NIGHT. THEN SHE HAD INSIDIOUS ONSET OF SOB GRADE I PROGRESSED GRADUALLY TO GRADE IV.

H/O PALPITATIONS

H/O OCCASIONAL CHEST PAIN

NO H/O PROFUSE SWEATING

H/O COUGH - NON-PRODUCTIVE SINCE 5 DAYS

NO H/O HEMATUURIA, BURNING MICTURITION, 

NO H/O ABDOMINAL BLOATING

NO H/O PAIN ABDOMEN, CONSTIPATION, LOOSE STOOLS,

NO H/O DECREASED URINE OUTPUT, FACIAL PUFFINESS

H/O PEDAL EDEMA +

PAST HISTORY

K/C/O HTN SINCE 2 YEARS IN AMLODIPINE AT 5/50

N/K/C/O DM, HTN, CVA, SEIZURES, ASTHMA, THYROID DISORDERS

PERSONAL HISTORY

BOWEL AND BLADDER – REGULAR

APPETITE – NORMAL

DIET – MIXED

SLEEP – ADEQUATE

FAMILY HISTORY

NO RELEVANT FAMILY HISTORY

GENERAL EXAMINATION

PT IS CONSCIOUS, COHERENT AND COOPERATIVE

WELL ORIENTED TO TIME PLACE AND PERSON

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING OR GENERALISED LYMPHADENOPATHY

VITALS – 

PR – 126 BPM

RR – 24 CPM

BP – 140/90 MMHG

SPO2 – 95% ON RA

GRBS – 140 MG/DL

SYSTEMIC EXAMINATION

CVS - S1 S2 HEARD NO MURMURS

RS - BAE, NVBS HEARD, FINE CREPTS HEARD BILATERALLY ON INSPIRATION

P/A - SOFT, NON-TENDER

CNS- NFND

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

ATRIAL FIBRILLATION, 

HEART FAILURE WITH ? COMMUNITY ACQUIRED PNEUMONIA

TREATMENT

1. INJ CEFTRIAXONE 1 GM IV BD

2. INJ LASIX 40 MG IV BD

3. INJ PAN 40 MG IV OD

4. TAB MET XL 25 MG PO BD

5. TAB APIXABAN 2.5 MG PO BD

6. TAB ECOSPIRIN 75 MG PO OD

7. TAB ATORVAS 30 MG PO HS

8. TAB TELMA 40 MG PO OD

9. 25 D WITH 8 U HAI IV/ OVER 1 HR

10. T AMIODARONE 200 MG PO STAT