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 

 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

45 year old male with weakness of upper and lower limbs and joint pains since 1 month

Image
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 . Cheif complaints: A 45 year old male construction worker by occupation came to the op with chief complaints of weakness of left upper and lower limbs since one month  Tingling sensation in left upper and lowe
Read more

My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE

Image
Warm greetings! I'm Ankit pachipulusu , a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you. The experiences of a medical student during college are heavily shaped by their inquisitiveness and often times teacher and peer pressure, as we pass through the treacherous waters of medical education in our rickety boats we come learn that doctors have many more obstacles in the form of beuracracy , testing targets etc. Apart from diagnosing and treating patients , All of these experiences have crafted a curiosty in me to explore the wider healthcare delivery system and various forms it is available in the world ranging from universal healthcare in the EU  to privat
Read more

34 year old female with itching and red lesions ( CASE TAKEN IN MARCH)

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT." 34 year old female  ,homemaker  by occupation comes to casualty with complaint of fever ,shortness of breath and dry cough  ,loss of appetite since 7 days. Chief  complaint high grade fever and cough with yellow colored  sputum since 5 days bilateral pedal edema (pitting type) since 5 days difficulty in breathing even at rest  (grade 4) since 5 days Generalized weakness since 5 days History of presenting illness The patient was apparently asymptomatic 1 yr back when she developed b/l knee joint pain and itching in upper aspect of chest and neck.The pain was insidious in onset and gradually progressive a
Read more