40 year age female with shock and hypothyroid since 10 years.

General medicine
M.Yashwitha
Roll.no:73.

This is 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 patients 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 comment box is welcome. 


I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.


40yr female came to casuality with complaints of

high grade fever since 5-6 days

C/o vomitings since yesterday

C/o loose stools since today .

History of presenting illness


Pt was apparently asymptomatic 5-6 days then she developed fever , sudden high grade not a/w chills and rigors , intermittent, releived temporarily on medication.


C/i vomiting since yesterday h/o 3-4 episodes , content good particles ,non bilious , non projectile , nausea present 


C/o abdominal bloating since yesterday

C/o SOB since yesterday , releived on lying down, 

No chestpain , palpitations PND orthopnea


C/o loose stools since today , watery consistency, 4-5 episodes ,small quantity, non blood stained , not associated with pain abdomen.


C/o epigastric pain since today , insidious onset , continuous , non radiating

Past history 

N/k/c/o HTN DM CVA CAD TB ATHMA


K/c/o Hypothyroidism since 10 years on tab. Thyronorm 100mcg /po/ od using irregularly since 15 days


On examination: 

Pt is c/c/c 

No pallor , icterus , cyanosis, clubbing, lympadenopathy, edema 


Vitals : 

PR: 124bpm

RR: 18cpm

BP: 70 systolic ( palpatory)

GRBS : 183mg%


CVS : S1 s2 heard no murmurs

RS BAE NVBS heard

P/A : epigastric tenderness present 

No free fluid.

Fever chart:


Investigations:










USG:




Diagonsis


HYPOVOLEMIC SHOCK SEOCNDARY TO ACUTE GE (RESOLVED) 

? COMMUNITY AQUIRED PNEUMONIA

WITH ? LEFT LOWER LOBE PNEUMONIA (BACTERUA US ATYPICAL) 

WITH ACUTE CALCULUS CHOLECYSTITIS 

Treatment 

IV FLUIDS NS & RL @100ML/HR 

(D4) TAB. AZITHROMYCIN 500MG PO/OD 8AM

T. THYRONORM 100MCG PO/OD 

   (8AM- 15MINS BEFORE FOOD) 

INJ. DROTIN IM/SOS

INJ. PAN 40MG/IV/BD 

INJ. ZOFER 4MG IV/BD 

MONITOR VITALS 4TH HOURLY.





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