Skip to main content

A 19yr old female SOB since 4 days primigravida with severe Anemia with left lung plueral effusion and left LL consolidation

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.

19year old female came to the casuality with the 
Chief complaints - 
-sob since 5 days 
-cough since 5 days
-fever 5 days

HOPI
Patient was apparently asymptomatic 4 months back then she developed cough (non productive) on and off, aggrevated 4 days back 
C/o vomtings since 4 months (on& off)
SOB since 4-5 days( grade 2) no h/o of orthopnea,palpatations,pnd,
H/o fever 5 days back high grade and associated with chills and rigor
No h/o pain abdomen, loose stools,burning micturation,cold

Past history
Not a k/c/o HTN,DM,asthma,thyriod 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- 80/40mmhg
F/b ns@ 700ml
Bp - 90/60mmhg
PR -102 bpm
RR-22cpm
Spo2 99% at room air 
Temperature -102 f

Clinical images
System 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 – midline 
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
Decreased tactile vocal fremitus in left lower lobe
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 8- 10 intercostal space) slight cre breath sounds

CNS: NFND

P/A: Non tender,uterus just palpated

Investigations on 2/6/23
Usg on 2/6/23

Provision diagnosis -
Primi gravida with severe anemia secondary to 
?Nutritional ?Hypovolemic shock with hypokalemia secondary to GI loss with left plueral effusion with left LL consolidation 

Treatment history - 
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

Internship Assessment

M Bhuvana phanindra Roll no:97 During my enriching tenure as a house surgeon at Kim's narketpally , I had the incredible opportunity to immerse myself in the diverse and challenging fields of General Medicine, Psychiatry, casualty and Nephrology. These rotations have not only expanded my clinical knowledge but also refined my interpersonal and diagnostic skills, preparing me to be a well-rounded medical professional. As I reflect on my journey as a house surgeon   I'm humbled by the rich tapestry of experiences I've encountered during my rotations in the general medicine department. In the General Medicine department, I encountered a myriad of complex cases that tested our diagnostic acumen. One notable scenario involved a young girl in her late teens  presenting with vague symptoms such as fatigue, jaundice and anemia. Through meticulous history-taking, physical examination, and collaboration with senior physicians, we successfully diagnosed an autoimmune disor
Post a Comment
Read more

65 years old patient with fever and suspected pneumonia

With UG learning is coming to be almost there to graduate the new case presented to OPD with complaints of fever M Bhuvana phanindra,  9th semister, Roll no.74. This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome As a part of "patient clinical data analysis" I was given this case to improve my clinical competence in reading and comprehending along with history taking , clinical findings, and investigations , investigations to come up with a diagnosis . This is the reflection of my case study: 65 year old female resident of Nalgonda came
Post a Comment
Read more

35M DM2 for 10years On Insulin 7 years Hypertension CKD2 years and now Amputated Foot

This is 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 patients 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 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. CASE HISTORY C/O of fever since one week high grade on and off Vomitings since 4days(5-6 episodes/day) Nausea + Swelling of Left Lower Limb since 4days(thigh to calf) Pain+, local rise of temperature+ HOPI - Patien
Post a Comment
Read more