40 years old male with Respiratory Distress syndrome secondary to community acquired pneumonia consolidation

 This is an E log book to discuss our patients de-identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis "to develop my competency and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.




A 40 years old male resident of nalgonda, a farmer by occupation 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 3 days ago, then he developed fever associated with chills and rigors. Later he developed dry cough, followed by SOB Grade 4 since 3 hours.

No h/o cold, nausea, vomiting, loose stools.


PAST HISTORY

Not a known case of Diabetes/Hypertension/TB/Asthma/Epilepsy/CVD


FAMILY HISTORY

Not significant

PERSONAL HISTORY

Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -no
Addiction -  intake of alcohol 
90ml daily 


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 +


Investigations 










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