General medicine


60yr OLD FEMALE WITH SHORTNESS OF BREATH. 

This is an online eblog book to discuss our patients deidentified health data shared after taking his or her/guardian  signed inform consent .Here we discuss our individual patients problems thorugh series of inputs from avaliable global online commity of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 

This e blog also reflects my patients centered online learning portfolio and your valuable inputs 

60yr old female came to opd with chief complaint of shortness of breath since 1 weak with history of recurrent fever, chills ,rigors,pedal edema and puffiness of face.


Then she was diagnosed by AKI after coming to faculty. She used to get severe knee pains ,she was using NSAID s from past 20 years
Since the Patient joined the hospital she came to know that she was diagnosed with diabetes and now she is under insulin

History of present illness:

Patient was asymptomatic 15 days back,
Then she developed shortness of breath
Bilateral lower limb pains
Pedal edema
Swelling of the face 
And decreased urine output
Complaints of chills and rigors 
She also developed fever(recurrent)
Cough
Burning micturation
Decreased urine output
No vomitings 

PAST HISTORY:

Known case of hypertension since 4 years
No h/o diabetes   asthama, thyroid ,epilepsy, tuberculosis 

PERSONAL HISTORY:

Apatite: decreased
Sleep :inadequate 
Diet: mixed 
Bowel movement:regular
Addictions:chewing of paan since 40 years ,and habit of toddy since 30 years

 FAMILY HISTORY:

Patient siblings has diabetes 

DRUG HISTORY 

 Patient does not have any drug allergy

General examination:

Patient is conscious, coherent , cooperative 
No pallor ,icterus and lymphadenopathy 
No cyanosis 
No clubbing if fingers
Edema of feet is present 

Edema resolved after she used medications and IV fluids

Vitals:

Temperature  97.8
Pulse rate 78bpm
Respiration 18/min
Blood pressure 110/70mmhg
Spo2 98%
Grbs 118mg

SYSTEMIC EXAMINATION:

CVS:
No thrills ,no murmers
S1,s2 sounds heard

Respiratory system:
No dyspnoea, no wheeze
Position of trachea is central 
Normal vesicular breath sounds heard
Tenderness at lower ribs
Bilateral air entry is normal
 
Abdomen:
No palpable mass is seen
Liver not palpable
Abdomen is non tender

CNS 
Pt is conscious 
Normal speech
No neck stiffness is present

Investigations:
Treatment:
Inj piptaz2.25grams iv
Inj lasiz 40mg iv
Tab nodosis 500 mg pd
Nebulizer daily twice

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