75 yr old male with c/o of SOB

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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 box is welcome.
Chief complaints:
pt came with c/o shortness of breath (today 9:00pm )

pt was admitted for similar complaints on 23/12/2020 and got discharged on 25/12/2020 with 
TAB. CARDIVAS3.125MG /OD
TAB.
ECOSRRIN AV (75120)H/S OD
TAB.CLOPIDOGREL 75 MG 
TAB.RAMIPRIL2.5MG OD
FORACART 200 MCG ×2 PUFFS×OD
pt is having SOB since 1year
H/O present illness
pt was apparently alright 1 yr back then he had insidious onset of SOB on exertion.he walks for some distance and takes rest for sometime and again continue walking.
on one day he had (1yr back) sudden onset of acute exacerbation of SOB not admitted for 4 days after getting discharged he used medication for 6 months (his symptoms improved) later he stopped using medication
no h/o fever, vomitings,loose stools,pain abdomen , pedal edema,chest pain, palpitation, urine incontinence
Past history:
not a k/c/o DM2/HTN/TB/EPILEPSY
Family history:
no history of DM2/HTN/TB/EPILEPSY in family
Personal history:
Mixed diet
Normal appetite
Adequate sleep
Bowel,bladder movements are normal
Chronic smoker(20 yrs, 2 per day),used to drink toddy occasionally
pt stopped alcohol and smoking beedi 20 yrs back 
General examination:pt is conscious , coherent and cooperative,no pallor , icterus,cyanosis,clubbing,koilonychia, lymphadenopathy,edema
Systemic examination:
CVS:S1,S2 heard
CNS: no focal neurological deficit
P/A: soft,non tender,no organomegaly
RS:BAE+, bilateral mild expiratory wheeze present at inframammary area.
VITALS 
TEMP: AFEBRILE
BP :160/100
PULSE:118bpm
RR:25CPM
DIAGNOSIS: ACUTE EXACERBATION OF COPD with new onset of RBBB
K/C/O HFREF(EF:32%)(LEFT HEART FAILURE)
Investigations:
ABG:
Day1:
Day2:
Haemogram:
CUE:
RFT:
LFT:
APTT:
PT,INR:
Troponin-I
Glycated haemoglobin:
ecg on 20/1
ecg on 21/1


Treatment:
Day 1
Nebulization with budecort 8 th hrly
And ipravent 8 th hrly
Inj lasix 20 mg IV/bd(SBP>100)
Tab ramipril 2.5 mg/po/of
Tab.cardivas 3.125 mg /po/od
Tab ecospirin-AV 75/200mg/po/od
Tab clopitab 75mg/po/od
Inj hydrocortisone 100 mg/iv/h/s
Inj deriphylline 1amp/iv/sos
Inj pan 40 mg/iv/bd
O2 inhalation with nasal prongs if required to maintain spO2>90%
Strict I/O charting
BP/PR/spO2/RR charting 4 th hrly
GRBS charting 8 th hrly
Day 2
Nebulization with budecort 8 th hrly
And ipravent 8 th hrly
Inj lasix 20 mg IV/bd(SBP>100)
Tab ramipril 2.5 mg/po/of
Tab.cardivas 3.125 mg /po/od
Tab ecospirin-AV 75/200mg/po/od
Tab clopitab 75mg/po/od
Inj hydrocortisone 100 mg/iv/h/s
Inj deriphylline 1amp/iv/sos
Tab pan 40 mg/po/od
O2 inhalation with nasal prongs if required to maintain spO2>90%
Strict I/O charting
BP/PR/spO2/RR charting 4 th hrly
GRBS charting 8 th hrly



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