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 yesterday, 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 .
Patient was able to do her work till Yesterday night ,since today she was unable to do her work with grade 2 sob which was progressed to grade 4 sob
Vomitings Since yesterday 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, palpation s present,
Complaints of decreased urine output since 10 days
No complaints of burning micturition
No complaints of fever ,cough ,cold
No pain abdomen
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
No addictions
No known allergies,
TREATMENT HISTORY:-
Surgery done for fibriod uterus in 2006
FAMILY HISTORY - Not significant family history
GENERAL EXAMINATION:
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing- absent
Lymphedenopathy - absent
Edema - absent
VITALS :
Temp - afebrile
Bp -110 /80 mmhg
Spo2- 95% at room air
RR - 32cpm.
SYSTEMIC EXAMINATION :
Cvs - S1S2 heard,no murmurs heard
Wheeze - absent
Dysponea - present
Position of trachea - central
Breath sounds - normal vesicular sound heard
P/A :
obese abdomen ,soft and non tender
CNS :
NAD
Investigation-
ECG admission 5/2/22 at 10: 50 pm
ECG on 7/2/22 at 9: 15 am
USG Chest on 7/2 /22 at 12 pm
Provisional Diagnosis:
septic shock
Treatment -
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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