Skip to main content

50/F WITH SOB SINCE 20 DAYS, ODYNOPHAGIA SINCE 3 DAYS

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 


15-March-2022 


A 50yr old female came with c/o shortness of Breath (grade 2) since 20 days

C/o difficulty in swallowing solids and liquids since 3 days

Not able to open mouth since 1 day


HISTORY OF PRESENT ILLNESS

Patient was apparently alright 10 yrs ago and went to Hospital in view of headache, easy fatigability and was diagnosed with hypertension and started on medications

6 years ago hospital in view of weight gain and easy fatigability and was diagnosed with Hypothyroidism and is using Thyronorm 50mcg

Later was diagnosed with Rheumatoid arthritis but is not on any medication 

3 months ago diagnosed with DM and is not in medication 

2 months back pt had c/o cough with expectoration, pain in chest region. Was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use she started developing redness and itching all over the body, ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back

20days back after being discharged from a hospital admitted for ATT induced Erythroderma. She is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.

From 3 days she is having difficulty in swallowing solids and liquids and from 1 day not able to open her mouth because of pain and c/o reddish discolouration of the tongue.


PAST HISTORY: 

k/c/o DM since 3 months, (not on medication) 

HTN since 10 yrs 

(On medication)

K/c/o Pulmonary miliary TB on ATT using 3 tablets /day ( HRZE)

K/c/o Rheumatoid Arthritis and not on medication

K/c/o Hypothyroidism since 6 years On Thyronorm 50mcg

GENERAL EXAMINATION

Pt is conscious, coherent and irritable

Pallor +

Icterus +

No cyanosis/ clubbing/ lymphadenopathy 











Allergic reactions were seen due to ATT 


















Vitals at the time of admission: 

Temperature:100F

PR: 98bpm

BP:130/80mm Hg

RR:27cpm

Spo2: 95%

GRBS:105gm%

CVS:s1s2 +

RS: BAE + , B/L crepts + (ISA, IAA)

P/A: soft, non tender , BS +



PROVISIONAL DIAGNOSIS:

Dysphagia under evaluation

Anemia under evaluation

?Plummer Vinson Syndrome

AKI secondary to ?pre renal ?UTI
Steven-johnson syndrome secondary to ATT with

Urosepsis with

Milliary pulmonary tuberculosis with

?nephrotic syndrome

DM,HTN, HYPOTHYROIDISM, RHEUMATOID ARTHRITIS

INVESTIGATIONS:



RBS: 70mg/dl
Blood Urea: 136mg/dl 
Serum iron : 45ug/dl
HbA1c : 6.8%
S. Creatinine: 4.8mg/dl
CRP: POSITIVE 2.4mg/dl (range: 0-0.6)
ESR: 70 ( range:5-20)
 
ABG
pH 7.34
PCo2 18.8
PaO2 92.4
HCO3 12.2
SpO2 96

LFT
TB 2.8
DB 0.74
AST 14
ALT 10
ALP 673
TP 7.4
ALB 2.23

CUE
ALB ++
Sugars nil
Pus cells plenty
Epithelial cells 1-2

COVID-19 RAT - NEGATIVE

ESR - 70
CRP - POSITIVE



USG Abdomen

ECG


LATERAL VIEW OF NECK


X RAY CHEST


HRCT CHEST



Few small volume medianal lumph nodes noted

Both lungs are studded with tiny nodular densities - Likely Milliary tuberculosis.

Small air filled cyst noted left lower lobe.

No evidence of effusion.

Non-obstructive left renal calculus.


Diagnostic nacendoscopy

https://youtu.be/eBKqDXlAd-8 

 Reference

https://venkata-phaneendra.blogspot.com/2022/03/a-50f-with-sob-since-20-days.html?m=1

Patient Referals

DERMA




ENT





 PULMONOLOGY



TREATMENT

IVF NS/RL/DNS @ 75 ml/hr

Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins




Comments

Post a Comment

Popular posts from this blog

54 Y/M with vomitings, SOB, fever

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 26 NOVEMBER 2023 Patient came to causality with complaints of Fever since 5 days SOB since 5 days Vomiting for 3 days The patient was apparently asymptomatic 5 days back then he developed fever, hi
Post a Comment
Read more

Medicine Journey

 My Journey Heyyy everyone This is Snitha Reddy Welcome to my blog Before hand only, this is my journey with medicine From 3 sem to intership My first case https://snithareddym89.blogspot.com/2022/03/59-y-female-with-vomitings-and-seizures.html Initially, I had no clue about the case We dived deep into history and ended up with differentials My pg alloted helped me under the case And I was fascinated to see the immediately response of the patient to the the treatment Understanding the concepts is the main core of the subject You can read the book but understanding it basing on the complaints of patients and orientating yourself to the flexibility of the treatment plan best suited for the patient Is the reaaaaall flex Some more in 5 sem https://snithareddym89.blogspot.com/2022/03/65-yf-with-burning-micturation-and.html https://snithareddym89.blogspot.com/2022/03/32-ym-with-shortness-of-breath-and.html https://snithareddym89.blogspot.com/2022/03/40-ym-with-abdominal-pain-and-vomitings.ht
Post a Comment
Read more

63 Y/F With Giddiness and headache

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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    13-NOVEMBER-2023 63 Y/F came to opd with C/O Giddiness and headache since 3 months  HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 3 months ago, then developed giddiness which
Post a Comment
Read more