THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
75F with COPD and Fever
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 suicide/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
Daily readings:
8.1.23
Temperature:
7am-97.2 F
1pm- 100.1 F
5pm-97 F
8pm-99.9 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
10/01/23
Temperature:
7am:96.1F
12am:96.1F
5pm: 97.8 F
9pm:97.3F
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
.jpeg)
16.1.23
17.1.23
18.1.23
19.1.23
20.1.23
21.1.23
.jpeg)
22.1.23
23.1.23
24.1.23
2.2.23
3.2.23
REPORTS:
HBA1C : 6.4SPUTUM COLLECTION:7.1.23
HBA1C : 6.4
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
23.1.23
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 1:55pm13.1.23Diet : 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
24.1.23
[17-08-2025 14.19] PPM 1: @PA any update on this patient's plantar fascitis pain shared on email earlier on 2015?👇
6/9/15- 8/9/15 bartoman poristhiti - betha nei tabe khichuni majhe majhei hochhe.Sorirer dan side ektu obosh obosh lagche.Thigh er nich thekei khichuni suru hoy.Tab Ultracet plain newar por theke buk dharfor o matha khanik khaner jonno ghure jachhe. Ultracet 1/ 2 dine dui bar o Paracetamol 500 mg dine 4 bar dewa hoyeche.
Date: Sun, Sep 6, 2015, at 11:04 AM
Subject: Re: 66yrs.F swelling in right leg
Hain half tablet.
On Sun, Sep 6, 2015, at 10:58 AM, patient advocate 65F wrote:
Ultracet Semi pawa na gele ultracet plain ki dewa jete pare!
On Sep 6, 2015, 9:58 AM, "cm wrote:
Shune mone hocche plantar fascitis
Local daktarer jonye suggestion.
Kichu diner jonye mild pain killer nite paren.
Tablet Ultracet Semi dine char bar ebong Tablet Paracetamol 500 mg dine char bar.
On Sat, Sep 5, 2015, at 9:28 PM, patient advocate 65F wrote:
Exactly goto 7 din theke sudhu payer patay betha chilo.Kichuni shuru hoyeche goto kal theke.Bichana theke namar somoy , hatte gele khichuni shuru hochhe , 1-2 minute thake, darate gelei problem hochhe.Mone hochhe pore gie paa venge jabe.
On Sep 5, 2015, 9:20 PM, "cm wrote: Kotokkhone thake?
On Sat, Sep 5, 2015, at 9:08 PM, patient advocate 65F wrote:
Goto 7 din theke dan payer thigh theke payer pata porjonto prochondo khichuni.Majhe majhe mone hochhe paa obosh hoye asche.Khichunir somoy betha hochhe.Paye support dite osubidha hochhe. Please need your help!
No comments:
Post a Comment