GM case -4

GM Case - 4

March 7,2023

A 55 year old lady came with a complaints of shortness of breath,left chest pain ,fever .

Case scenario:

My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.
 

Cheif complaint: 

Shortness of breath since 2 days
Left chest pain since 2 days
Fever since 2 days
Dry cough since 1 day
Edema - on and off

History of present illness:

Patient is apparently asymptomatic 2 days back and suddenly developed shortness of breath which shifted from Grade 2 to Grade 3 progressively, left sided chest pain with fever .She complained of dry cough since 1 day which is sudden in onset gradually progressive and decreased urine output since 1 day.No agressive and relieving factors.

History of past illness:

Patient is not a known case of Hypertension, Diabetes mellitus, Tuberculosis,Asthama,CAD, Epilepsy.
10yrs back an accident,replacement with rod.

Personal history: 

She wakes up in the morning at 6 am and have breakfast and rest...she is a house wife (6 am to 10 pm).
Diet - Mixed 
Appatite - Normal
Bowel - regular
Micturition - regular 
Addictions - No


Family history: 
Not seen  in her family.

General examination:

Thin built moderately nourished
Consicuous
Pallor - seen 
Icterus- seen
Cyanosis - not seen 
Clubbing - not seen
Edema - present 

Vitals: 
Temperature - febrile
Bp - 120/70 mmhg
PR- 104bpm
RR -21 cycles/ min

Systemic examination: 

Respiratory system - bronchial artery embolization seen
CVS - S1 S2 sounds heard

Provisional diagnosis:

CKD - as she has Pedel edema and SOB
Pleural effusion - chest pain Dry cough dyspnoea orthopnea .

Investigations: 




Definitive diagnosis: 

Left pleural effusion
Hypertension
Hyperkalaemia
Hyponatremia
Pyrexia decrease with anemia
Perianal abscess 
CKD

Questions:

Wt are the causes of embolization??
Which side of pleural effusion is common??


Popular posts from this blog

GM case - 5

Image
GM case - 5 March 7 ,2023 A 77 year patient came with a cheif complaint of difficulty in breathing, abdominal pain with bloating and abdominal distension. My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.  I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan. Cheif complaint: Difficulty in breathing since 3 days Abdominal pain since 3 days Abdominal distension since 3 days  History of present illness: Patient is apparently asymptomatic be...
Read more

GM case- 7

Image
GM Case 7  18 July 2023  30 year male patient came to opd with a complaints of Vomitings  loose stools Shortness of breath since 7 days.  Case scenario: My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs. I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan. CHIEF COMPLAINT : Vomitings since 7 days  Loose stools since 7 days  Shortness of breath since 7 days  HISTORY OF PRESENT ILLNESS : Patient was apparently asymp...
Read more

GM CASE 9

Image
GM case - 9 6 th August 2023 37 year male came to opd with a chief complaint of shortness of breath, decreased urine output,pedel edema, abdominal distension,facial puffiness since 8 days . Case scenario: My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs. I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan. Chief complaint: Shortness of breath Pedel edema Decreased urine output Facial puffiness Abdominal distension  All since 8...
Read more