A 40 year old female with community acquired pneumonia

 DR.CHETANA (INTERN)


DR.NAVYA (INTERN)


DR.ABDUL RAHEEM (INTERN)


DR.ASHFAQ(INTERN)


DR.SRAVYA(INTERN)


DR.GNANADA(INTERN)


DR.CHARAN(PG1)

       

  DR.CHANDANA (PG 1)


DR.SUSMITHA(PG2)


DR.ADITHYA (PG3)


DR.PRANEETH(PG3) 


DR.PRAVEEN NAIK (ASS.PROF)


DR.RAKESH BISWAS(HOD)




This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 



Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case I have seen -

Unit 1 admission on 8/3/21

A 40 year old female came with c/o fever since 4 days and SOB since 1 days 
HOPI- 
Pt is k/c/o polio since age of 8 months with deformed lower limbs and spine since childhood. Inspite of her deformities ...she used to do all her chores by herself like cooking , washing, cleaning and completed her 10 th class 
She was alright till 6 years back . 
6 years ago she had history of fever and cough during which she was diagnosed with pneumonia and took some injections near the local RMP ? Antibiotics .
Since 10 months, she reports decreased appetite , indigestion and on and off chest pain after eating meals.
History of weight loss of 5 kgs since last 10 months.
Since 4 days, she complains of high grade fever, intermittent type , not a/w chills and rigors, relieved on medication, no diurnal variation.
C/o dry cough since 3 days.
H/o vomitings 2 days back, 3 episodes with food as content.
H/o of loose stools 2 days back, 3 episodes, watery in consistency, in small volumes.
Vomitings and loose stools subsided now.
Since yesterday evening, she developed SOB which progressed from Grade 1 to Grade 4.
She presented to casualty with GRADE 4 SOB.
No h/o burning micturition, chest pain , cold.
Not a K/C/O DM HTN TB Epilepsy CAD
Decreased appetite 
Regular B&B movements 
Menstruated history - 
AOM 12 yrs
Cycle - 4/30
Regular
No clots, no dysmenorrhea
General examination-
Wt -

Pallor-present 
No signs of icterus , cyanosis , clubbing, 
No generalised lymphadenopathy, generalised edema 
Vitals -
Temp-102F 
Bp-140/90mmhg
PR-135 bpm 
RR-34cpm
SPO2- 90 @ 4 lit O2
GRBS-137mg/dl 
Calluses present over fingers and plantar aspect of foot 
Flexion deformities of both lower limbs 
Flat nails 
Kyphoscoliosis is present 
On examination-
RS- 
Dyspnea-present
Wheeze -present 
B/L Parasternal bony prominences + (clavicle)
B/L coarse crepts + , not subsiding with cough in Rt ICA, IMA, IAA and Lt IAA 
P/A-
Shape of abdomen- normal 
Non tender 
No palpable mass 
Hepatomegaly is present 
CVS-
S1,S2 +, 
Tachycardia Is present 
No cardiac murmurs 
CNS- NAD
Provisional diagnosis-
Community acquired pneumonia 




















Comments

Popular posts from this blog

A 63 YEAR OLD MALE WITH MOVEMENT DISORDER

45 year old male with abdominal distension

35yr old female with ? Cervical lymphadenopathy