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.
Chief complaint:
70 Year old female patient presented to OPD with the chief complaints of sob since 5 days, vomitings since morning,loose stool 2-3 episodes, complaints of Lump over left back.
History of present illness
Patient is apparently asymptomatic 3 years ago.
patient went to regular check up diagnosed with Hypertension and she was on regular medication.
she was unable to do her work with grade 2 sob which was progressed to grade 4 sob .
Vomitings Since today 3-4 episodes ,food particles as a content.
Complaints of Loose stools, 2- 3 episodes
Complaints of lump over left back ,tenderness present and no local rise of temperature
No orthopnea ,No PND, no chest pain,no syncopal attack.
Complaints of decreased urine output since 10 days
No complaints of burning micturition
No complaints of fever ,cough ,cold
Past history:
History of Hypertension and on regular medication since 2 years .
No history Dm,Asthma, epilepsy, TB,CAD .
She underwent fibroid operation of uterus 18 yrs ago.
Personal history:
Diet: mixed
Appetite : normal
Bowel and bladder : loose stool
No addictions
Sleep - adequate.
Family history:
No relevant family history.
Treatment history:
Not allergic to any known drugs.
Pt is taking medicines for hypertension.
General examination:
Pt is conscious coherent and cooperative. Moderately nourished and moderately built.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing- absent
Lymphadenopathy - absent
Edema - present
VITALS :
Temp - afebrile
Bp - 90 /60 mm Hg
Pulse rate - 90 beats/ min
SpO2- 95% at room air
RR - 32cpm.
Systemic examination:
CVS -
Chest wall is bilaterally symmetrical S1,S2 heard,
no murmurs heard
RESPIRATORY system:
Wheeze - absent
Dyspnoea - present
Position of trachea - central
Breath sounds - normal vesicular sound heard
basal crepts heard
Per Abdomen :
obese abdomen ,soft and non tender
CNS : no abnormalities detected
Provisional Diagnosis:
Septic shock , AKI. And pleural effusion.
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
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