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










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