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 COMPLAINTS:-
70 Year old female patient presented to OPD with the cheif complaints of sob since 5 days and also complaints of vomitings since 2days, loose stools 2-3 episodes, complaints of lump over the left back buttock region.
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 3 years ago.
Patient went to regular check up and diagnosed with Hypertension and on regular medication .
Patient was able to do her work till day before yesterday night ,since yesterday she was unable to do her work may be because of grade 2 sob which was progressed to grade 4 sob.
Vomitings Since yesterday 3-4 episodes ,food particles as a content in the vomitings.
Complaints of Loose stools, 2- 3 episodes per day.
C/0 lump over left back buttock region,tenderness is 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
No pain in the abdomen over left back.
PAST HISTORY:
History of Hypertension and on regular medication since 2 years . No history Dm,Asthma, epilepsy ,TB,CAD
PERSONAL HISTORY:
Diet: mixed
Appetite : normal
Bowel and bladder : loose stool
Sleep: adequate
No addictions
No known allergies.
TREATMENT HISTORY:-
Surgery was done for fibriod uterus in 2006.
FAMILY HISTORY:-
No similar complaints seen in the family members.
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.
PR:- 89bpm
SYSTEMIC EXAMINATION:-
Cvs :- S1S2 are heard,no murmurs are heard
Wheeze - absent
Dysponea - present
Position of trachea - central
Breath sounds - normal vesicular sound heard
Per Abdomen:-
obese abdomen ,soft and non tender
Bilateral pitting edema is seen:-
INVESTGATIONS:-
Hemogram:
USG ABDOMEN:-
USG CHEST:-
CHEST X-ray:-
PROVISIONAL DAIGNOSIS:- Septic shock secondary to AKI and pleural effusion.
TREATMENT:-
1.INJ MEROPENEM 500 MG IV
2.INJ CLINDAMYCIN 600 MG IV TI
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.
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