T.shalini General medicine case presentation

 General medicine final practical long case presentation :

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:

70 Year old female patient presented to OPD with the cheif complaints of sob since 5 days and also complaints of vomitings since morning, loose stool 2-3 episodes, complaints of Lump over left back.

HISTORY OF PRESENT ILLNESS : 


Patient apparently asymptomatic 3 years ago

Patient went to regular check up diagnosed with Hypertension and on Regular medication .          

 she was unable to do her work with grade 2 sob which was progressed to grade 4 sob 

Vomitings Since 3 days of  3-4 episodes ,food particles as a content

Complaints of Loose stools, 2- 3 episodes 

C/0 lump over left back ,tenderness present and no local rise of temperature

No orthopnea ,No PND, no chest pain,no syncopal attack, palpations present,

Complaints of decreased urine output since 10 days

No complaints of burning micturition 

No complaints of fever ,cough ,cold

No pain in abdomen .


PAST HISTORY:

History of Hypertension and on regular medication since 2 years .

 No history Dm,Asthma, epilepsy , Tuberculosis.

 


PERSONAL HISTORY:


Diet: mixed 

Appetite : normal 

Bowel and bladder : loose stool 

No addictions 

No known allergies.


TREATMENT HISTORY:- 

Surgery done for fibriod uterus in 2006

FAMILY HISTORY - Not significant! 


GENERAL EXAMINATION:


Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing- absent

Lymphedenopathy - absent

Edema - absent


VITALS : 

Temp - afebrile

Bp -90 /60 mmhg

Spo2- 95% at room air

RR - 32cpm. 

SYSTEMIC EXAMINATION : 


Cvs - S1S2 heard,no murmurs heard

RS:Wheeze - absent

Dysponea - present

Position of trachea - central 

Breath sounds - normal vesicular sound heard 

Adventitous sounds - basal crepts heard 

Per abdomen

obese abdomen ,soft and non tender 

CNS : 

No abnormalities detected.


Chest Xray :

USG abdomen:


USG chest:


ECG:



Provisional Diagnosis: 


An Intriguing case of septic shock ,pleural effusion,acute kidney jnjury


Treatment - 

1.INJ MEROPENEM 500 MG IV BD

2.INJ CLINDAMYCIN 600 MG IV TID

3.INJ HYDROCOT 100 MG IV BD

4.NEBULISATION WITH DUOLIN AND BUDECORT 6HRLY

5.IVF NS @30 ML + OU 

6.INJ PAN 40 MG IV OD 

7.INTERMITTENT CPAP 6TH HRLY 

8.INJ VANCOMYCIN 1 GM IN 100 ML NS OVER 1 HR OD.







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