40 years old male with Respiratory Distress syndrome secondary To community acquired pneumonia with right upper lobe,middle lobe,lower lobe consolidation and left upper lobe consolidation

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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

 40 years old male  resident of nalgonda who is farmer came to the hospital with the complaints of 

CHIEF COMPLAINTS
C/o  Fever since 3 days 
C/o cough (dry cough) since 3days 
C/o shortness of breath grade 4 since 3 hours 


HISTORY OF PRESENTING ILLNESS
Patient  was apparently asymptomatic  3days ago then he had fever  associated with chills and rigors  then he developed dry cough,And then developed SOB Grade 4 since 3 hours.
No h/o cold, nausea, vomiting, loose stools.



PAST HISTORY
Not a known case of
Diabetes 
Hypertension
Tb 
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -no
Addiction -  intake of alcohol 
90ml daily 

Daily routine before 10 days
5:00 woke up
6-7:00 had breakfast and tea
10:00 went to work
2:00 lunch
3:00 taddy daily + alcohol 
8-9:00 dinner( when take alcohol he never had breakfast.without alcohol he will have food)
 9:30 sleep

GENERAL EXAMINATION
Thin built and malnourished 

Vitals
Temperature : Afebrile 
Pulse: 90
BP:120/70 mm/ hg
RR :26
SPO2 : 92%
GRBS:127 MG%

Pallor : ABSENT 
Icterus : ABSENT 
Clubbing :ABSENT
Cyanosis :absent
Lymphadenopathy: absent
Pedal edema: absent

SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs

ABDOMEN EXAMINATION

RESPIRATORY SYSTEM

dyspnoea wheeze+
Central trachea 
Bilateral air entry +
Bilateral basal crepts +


Investigation 

Popular posts from this blog

PARAPARESIS

Image
I've been given this case data to solve in an attempt to understand and analyize the topic " PARAPARESIS " based on patient clinical data in order to develop competency in reading and comprehending clinical data related to Paraparesis and come up with a suitable diagnosis. You can find the original case in the link below- https://vaish7.blogspot.com/2020/05/medicine.html?m=1 FOLLOWING IS THE PROBLEM LIST ACCORDING TO PATIENT'S PRIORITY : MAIN COMPLAINTS : Weakness of both lower limbs Vomitings Gluteal abscess Scrotal abscess EACH COMPLAINT IN DETAIL :      1.  WEAKNESS OF BOTH LOWER LIMBS : ONSET :Sudden Since 5 days ASSOCIATED SYMPTOMS :Tingling and Numbness PAST HISTORY :had a fall when he got up for urination and was picked up by his father PROBABLE DIAGNOSIS : Peripheral Neuropathy INFECTIVE SPONDYLODISCITIS(spine infections-Most commonly-Tuberculosis) Gullian-Barre Syndrome/Multiple Sclerosis Sciatica Myasthenia Gravis Spinal lesion or tumor/Toxins INVETIGATIONS
Read more

ALTERED SENSORIUM SECONDARY TO RECURRENT HYPOGLYCEMIA (RESOLVED) WITH VIRAL MENINGO ENCEPHALITIS (RESOLVED) WITH K/C/O DM-2 WITH CHOLILITHIASIS WITH LEFT CORTICAL CYST

Image
 A 70yr old female with involuntary movements in upper and lower limb MEDICINE E LOG BOOK “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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.” CHIEF COMPLAINT Patient came to casualtiy with altered sensorium with involuntary movement in Right upper limb since 12:00 am, c/o loss of speech and no  movement  in left upper limb and lower limb after 12:00 am pt had h/o 3 episodes of involuntary micturition since  5 days , c/o one episode of fever  2 days back which was relieved on medication . On the way to the hospital PT grbs was found to be 15 mg/dl and a
Read more