respiratory

Unit 3 admission
ICU
A 60 yr old female came with C/O SOB grade 3-4 from past 5days progressive in character,no diurnal variation 
HOPI: patient was apparently alright 10yrs back where she had an episode of shortness of breath ,cough with expectoration and was taken to hospital relieved after 2-3 days 
She had intermittent episode of acute exacerbation yearly twice ( for which she had to be hospitalized) 
Past history:
She gave long history of usage of bio fuel since childhood and still uses it now and then as she recalls 
She is diagnosed to be diabetic
4 yrs back (was detected incidentally during hospitalization),-on medication since 4 yrs
Denies history of TB/Epilepsy/HTN ,she was using medication for cough(not documented)
Personal history:
Appetite: normal
Bowel- reduced frequency of passing stools
Micturition -normal
Takes alcohol occasionally
No significant family history
General examination:
Pallor:present
No cyanosis,icterus, lymphadenopathy
Clubbing of fingers -present
Temp:98.4F
PR:110 BPM
RR:30 cpm
BP:130/80 mmHg
SPO2: 90percent
GRBS: 238
CVS:S1,S2 heard
RS: dyspnea present,wheeze present
On inspection:
Tachypenic
On percussion:hyper resonant in all lung fields 
Ascultation: polyphonic wheeze in all areas ,
Basal coarse crepitations on both sides

Crepitations+ in all lung fields
Abdomen -distended
CNS-NAD
Provisional diagnosis:
Chronic bronchitis,acute exacerbation of COPD,with uncontrolled type 2 DM and old coronary artery disease
SOAP NOTES 
AMC Bed 1
S:Patient complaints of cough

O
Temp:98.2f
Bp:130/80mmHg 
Pr:61bpm 
Rr:22cpm
Cvs:s1s2+
Rs:BAE +
  Left-ICA,IMA,ISA,
       Inspiratory creps present 
P/A Soft,NT,Exp wheeze present 
CNS:No FND
A:
Acute exacerbation of COPD with corpulmonale with old CAD
P:
1)IVF-NS 1 unit @75ml/hr
2)Neb with Foracart 8th hrly
3)Inj Augmentin 1.2gm iv .bd
4)Inj insulin s/c
5)Tab PCM 650mg/po/sos
6)Syp Ascoril D.po.bd
7)Vitals monitoring
8 GRBS monitoring 6 hrly
9 I/o charting8am
SOAP NOTES 
WARD PATIENT 
S:Patient complaints of cough

O
Temp:98.2f
Bp:120/80mmHg 
Pr:88bpm 
Rr:21cpm
Cvs:s1s2+
Rs:BAE +
  Left-ICA,IMA,ISA,
       Inspiratory creps present 
P/A Soft,NT,
CNS:No FND
A:
Acute exacerbation of COPD with corpulmonale with old CAD
P:
1)IVF-NS 1 unit @75ml/hr
2)Neb with Foracart 8th hrly
3)TAB Augmentin 625MG PO/ TID
4)Inj insulin s/c
5)Tab PCM 650mg/po/sos
6)Syp Ascoril D.po.bd
7)Vitals monitoring
8 GRBS monitoring 6 hrly
9 I/o charting

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