Medical case

 75F with COPD and fever

This is an online e blog to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

PAST HISTORY:

The patient is 75 years old female. She is a retired school teacher and is managing her tea gardens now. In the year 1990 she was detected with cyst in her right breast. She went to doctor with complaints of severe pain and swelling. Biopsy result was good and operation was done. She is suffering from cough and cold every winter since 1992. Though  the last two years were not severe. She has high pressure(since 1992) and anxiety. She went to doctor with complaints of severe vomiting, headache, acidity and high pressure.  Only one of her doctor(local PHC) said she has bronchitis in the year 2010. Currently she is taking Stamlo 5,Beta 40/25,Omez D . She had taken antibiotics (clavam 625mg) and cough syrups in her initial years of  cough and cold. After that she had taken inhalers such as budecort and duolin in the year 2017 (only when she felt difficulty). 

She also had brain stroke in 2018(march), her symptoms were high blood pressure and severe headache, she again had brain stroke in 2022.

 In late 2020, she started taking nebulizer. Currently, the patient is suffering from severe breathing difficulty and fever. She is bedridden since 7th January, distressed and is not able to use the washroom without support.

 She has chronic anxiety (worried about family members) and wheezing. She didn't think she would suffer like this which is causing her mental distress and breakdown.  She is feeling like a burden which is causing her mental trauma. Her appetite is also less. She is feeling like a burden on her family. She is not able to cope up with the situation that she is so sick. She says she wants to die without any pain with a smile plastered on her face. She is not able to accept that she is 75 as she didn't think she would survive. She is termed as a dominant, headstrong ,independent woman by her family members so when she has to ask for help she isn't feeling good. She couldn't accept the fact that she is becoming weak so she is getting aggressive and irritated. She is getting tensed thinking about her 3 grand-children, what will happen to them if she is no more. Though her family members can see her mentally strong. Moreover few days back(29.1.23) she has lost one of her elder brother whom she loved dearly. She is tensed thinking about her son. Her daughter in law is ignoring her, wouldn't let her daughter meet her. She thinks the disease is communicable. She is getting anxious thinking that a huge war will break out after her death for property between son and daughter.

FAMILY HISTORY:
 
She is a widow with 2 children and 3 grandchildren. 

Father(late)- He had cough and cold. Died because of brain stroke.

Mother(late)- She also had cough and cold. Died because of brain stroke.

Sisters(2)-  one of them had Died because of  brain stroke. 
Brothers(6)- two of them Died because of brain stroke, one of them Died of liver cirrhosis, one suicided/murdered and one of them Died because of brain stroke and heart failure. 

CHIEF COMPLAINTS:(06.1.23)


Fever
COPD
Low SpO2

DRUG HISTORY:

Stamlo 5
Telma Beta 40/25
OmezD
Budecort
Duolin
Paracetamol 650mg

HISTORY OF FEVER:





Daily readings:

8.1.23

Temperature:
7am-97.2 degree F 
1pm- 100.1 degree F 
5pm-97 degree F 
8pm-99.9 degree F 
 
Sp02:
7am-92
1pm-96
5pm-92
8pm-92

Heart rate (HR):
7am-94
1pm-100
5pm-96
8pm-96

Respiratory rate(RR):
1 pm- 30
5pm-16

9.1.23







10.1.23:

Temperature:
 7am:96.1degreeF
12am:96.1degreeF
5pm: 97.8 degreeF
9pm:97.3 degreeF

RR:
 7am:26
12am:17
5pm:19
9pm:21

HR:
7am:90
12am:78
5pm:81
9pm:83

SpO2:
7am:98
12am:92
5pm:85
9pm:90

BP:
7am:136/85
12am:107/74
5pm:138/81
9pm:131/93

11.1.23


12.1.23


13.1.23


14.1.23


15.1.23


16.1.23





17.1.23


18.1.23


19.1.23


20.1.23


21.1.23

22.1.23


23.1.23
24.1.23
2.2.23

3.2.23
REPORTS:




SPUTUM COLLECTION:

7.1.23
8.1.23
9.1.23
10.1.23

11.1.23
12.1.23
13.1.23
14.1.23
15.1.23

16.1.23
17.1.23
18.1.23
19.1.23
20.1.23
21.1.23
22.1.23



23.1.23
24.1.23

2.2.23
4.2.23
5.2.23

The previous sputum had two parts-one getting collected in the bottom due to higher density than water with some mass and other in upper layer with lower density than water.

In recent picture it is seen that it is getting collected in the top due to lower density than water.

DIET:

10.1.23

Tea,Digestive biscuit,Egg, Dahlia, Rice,Fish Sabji, Vegetables soup,Chana was her diet in a small amount

11.1.23
Lunch around 1:55pm

13.1.23

Diet :Tea biscuit, Boiled rice,Dal, sabji, Egg, Apple pulp, Amloki,Rice,vegables,Fish,tea, biscuit, cheese, vegetables soup,milk roti.

14.1.23


15.1.23
16.1.23
17.1.23











19.1.23
20.1.23




21.1.23


22.1.23
23.1.23




24.1.23







Comments

Popular posts from this blog

Medical case

How heart points are being calculated in Google fit?