A. 70 yr old female with pneumonia











This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

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.

Here is a case i have  seen :
A 70 year old female came with c/o shortness of breath since yesterday night ,fever since 2 days ,cough since 2 days ,vomitings since 1 day (1episode yesterday, 2 episodes today)
Patient was apparently asymptomatic 3 days back attended a party and had cool drinks and then next morning developed fever with cough then developed vomiting 1 episode at 4 pm then pt was normal till 8 pm night then started developing shortness of breath which was sudden onset went to RMP and took some medications and went back home patient was normal till next day morning then she started developing SOB which aggravated with supine position and releived by sitting position  and then pt had 2 episodes of vomitings (non bilious and containing food particles ) and patient was taken to local hospital and referred to kims for further evaluation 
Not a k/c/o DM ,HTN,TB,Asthma ,epilepsy 
No addictions

MENSTRUAL HISTORY
Age of menarche 13 years 
Bleeds 3/28 days 
No dysmenorrhea 
Not associated with clots 
O/E 
Patient is conscious coherent coperative 
Vitals 
Bp -110/70
PR -110 bpm 
RR - 22 cpm 
Spo2 98@room air 
Systemic examination 
Cvs -s1s2 +
Respiratory system -Inspection shape of chest normal 
Position of trachea appears to be central 
Movements of chest normal 
RR-during admission 46 decreased to 22
Palapation-


P/A -soft , non tender ,no organomegaly 
CNS -normal 
Provisional diagnosis-pneumonia 


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