Final Practical Long case

 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.

HISTORY OF PRESENT ILLNESS : 

Patient apparently asymptomatic 2year 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 today 3-4 episodes ,food particles as a content
Complaints of Loose stools, 2- 3 episodes 
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! 

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
Wheeze - absent
Dysponea - present
Position of trachea - central 
Breath sounds - normal vesicular sound heard 
Adventitous sounds - basal crepts heard 
P/A : 
obese abdomen ,soft and non tender 
CNS : 
NAD


Investigation- 
ECG
ECG 
ECG 
USG Chest 

2D ECHO-




USG abdomen  


Chest X Ray





Provisional Diagnosis: 

An Intriguing case of 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  ODCheif complaints:

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