19yr old female SOB since 4 days

 This is an online e log book 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 inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

19 year old female came to the casuality with the 
CHIEF COMPLAINTS - 
SOB since 5 days 
COUGH since 5 days
FEVER 5 days 

Patient was apparently asymptomatic 4 months back then she developed cough (non productive) on and off, aggravated 4 days back and relieved on medication
SOB since 4-5 days( grade 2) aggravated on changing position on bed while sleeping Associated with sharp pain, orthopnea present
No h/o palpitations, PND 
H/o Fever 5 days back high grade and associated with chills and rigor 
No h/o pain abdomen, loose stools,burning micturition,cold

PAST HISTORY -
She was taken to private hospital where she was diagnosed with left pleural effusion and left lower lobe consolidation 
Not a k/c/o HTN,DM,asthma,thyroid disorders, CAD, epilepsy,CVA

PERSONAL HISTORY -

Diet - Mixed 

Sleep - Adequate 

Appetite - normal 

B&B - regular 

No addictions 

MENSTRUAL HISTORY -

Menarche - 13 yrs

Menstrual cycle - 5/28

LMP - 2/1/23

Gravida - 1
 
Family history- 

No significant family history
 
General examination -

Patient was conscious coherent co-operative
 
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS
BP- 110/70mmhg

PR -102 bpm

RR-22cpm

Spo2 99% at room air 

Temperature -102 F

Clinical images





 SYSTEMIC EXAMINATION 

CVS: S1 S2 heard , jvp not raised,apex beat pounding 


RS: 
UPPER RESPIRATORY TRACT:
No Halitosis
No oral thrush, 
No postnasal drip, pharyngeal deposits, tonsils
No sinus tenderness

LOWER RESPIRATORY TRACT:
INSPECTION:
Chest is symmetrical
Trachea – Central 
No supraclavicular/infraclavicular  hollowing
No Sinuses, scars, dilated veins, nodules
Movement with respiration, use of accessory muscles of respiration

PALPATION:

Trachea – midline
No Kyphoscoliosis,
No dilated veins – direction of flow, nodules
Chest movement normal

PERCUSSION:
Right/Left -  slight dullness noted in left lower lobe

AUSCULTATION-  bilateral air entry was present and decreased breath sounds in the left lower lobe ( over 5-6 intercostal space)

CNS: NFND

P/A: Non tender,soft

Investigations on 2/6/23


USG on 2/6/23




PROVISIONAL DIAGNOSIS -

Primi gravida with  severe anemia secondary to ? Nutritional? Hypovolemic shock with hypokalemia secondary to GI loss with left pleural effusion with left LL consolidation 

 TREATMENT - 
One unit of prbc transfusion was done 
1.Iv fluids NS,Rl 50ml/hr
2.Augmentin 625 po/od 
3.inj.zofer sos /iv
4.Tab. DOLO po/sos
5.inj NEOMOL 1gm iv /sos if temp> 101.2f
6. Syp.dextromethorphan
2tsp po/TID

Comments

Post a Comment

Popular posts from this blog

55 F WITH LOW BACK ACHE SINCE 15 YEARS

Image
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."  CHIEF COMPLAINTS  55 year old female from Assam came with the CHIEF COMPLAINTS of lower back ache since 15 years . HISTORY OF  PRESENTING ILLNESS  Patient is a resident of Assam married at the age of 18 years ,started working in farms 4 years after her marriage ,her work many consisted of  ploughing and sowing ,transplanting the sampling requiring her to bend forward and lean for several hours (5-10hrs/day) She gave birth to her first child 2 years after marriage
Read more

49 yrs old male with HF and CKD

Image
 Chief complaints Right lower limb swelling since 10 days, fever since 5 days History of presenting illness Patient was apparently asymptomatic 10 years back then he developed progressive swelling of right lower limb and diagnosed with filariasis for which he was prescribed medicines by a local doctor 10 year back he was diagnosed with diabetes mellitus and hypertension and since then using antihypertensives( nifedipine) and anti diabetics( glizide) - 3 years back he developed pedal oedema and went for further evaluation and diagnosed to have chronic renal failure ? - 2 years back he suffered from COVID-19 following which he had shortness of breath at rest (grade 4) and chest pain for which he went to co-operate hospital in Hyderabad and diagnosed to have inferior wall myocardial infarction, So he was treated with streptokinase. At that time coronary angiogram was not done in the view of high serum creatinine levels - After 1 month coronary angiogram was done to recanalized the right c
Read more

39 year old male patient presents to casualty with complaints of shortness of breath

Image
A 39 year old male came to the casualty around 10 pm with  Chief complaints of sob since 3 days.  Fever since 10 days Cough since 10 days Chest pain since 10 days Pain abdomen since 10 days HOPI :  Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. Then patient got tested positive for Widal after 4 days of onset of fever. He used symptomatic medication for a week. Then, he developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed from grade 2 to grade 4 since past 10 days, SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days Past History : Admitted to a hospital for pain abdomen for 4 days Not a k/
Read more