Final Practical examination -Long case

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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.

CHIEF COMPLAINT:-

70 year old female patient ,hailing from Nakrekal presented presented to Opd with chief complaints of sob since 5 days , vomitings since one day ,lump over left back and loose stools of 2 to 3 episodes .

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 3 years back .she went to regular checkupt there she was diagnosed with Hypertension and she is on regular medication.2 days back her Sob was progressed from grade 2 to grade 4 and she is not able to do her work .

Vomitings since one day  3 to 4 episodes with food particles as a content 

Complaints of loose stools of 2 to3 episodes.

Complaints of lump over left back, tenderness is present and no local raise in temperature.

Patient also complains of decreased urine output since 10days .

No PND ,no syncopal attack 

No complaints of fever ,cough ,cold 

No complaints of burning micturition .

PAST HISTORY:-

Known case of hypertension since 3 years and she is on regular medication.

No history of DM,Asthma ,Epilepsy ,TB ,CAD.

PERSONAL HISTORY:-

Diet -mixed 

Apetite-Normal 

Bowel and bladder movements-loose stools and decreased urine output

Sleep -adequate

No addictions

TREATMENT HISTORY:-

She had a surgery for fibroid uterus 16 years back .

FAMILY HISTORY:-

No relevant family history 

GENERAL EXAMINATION:-

Patient is conscious ,coherent, not so cooperative.

pallor-present

No cyanosis,No clubbing ,No icterus,No lymphadenopathy.

Bilateral pedal edema is present .

VITALS :-

Temperature-afebrile

Respiratory rate-32 cycles /min

Pulse rate -89 beats /min 

Blood presssure-90/60mm Hg

SYSTEMIC EXAMINATION:-

CVS-:-

Inspection

-chest wall is bilaterally symmetrical

-No precordial bulge 

Palpation-JVP is normal

Auscultation-S1,S2 sounds are heard 

No murmurs 

RESPIRATORY SYSTEM:-

Dyspnea-present 

No wheeze 

Position of trachea-central 

Normal vesicular breath sounds 

ABDOMEN:-

Obese abdomen 

-Abdomen is non tender 

-Bowel and bladder sounds heard 

-No palpable mass or free fluid 

INVESTIGATIONS:-

HEMOGRAM:-

Hemoglobin-11 gm/dl

Total count-31,100 cells/cumm

Neutrophils-87%

Lymphocytes-05%

Monocytes _7%

Eosinophils-1%

PCV-31vol%

RBC -3.52millions /cumm

Platelet count-1.5lakhs/cumm

Smear -Normocytic Normochromic

CHEST X-ray 

USG abdomen

USG chest

PROVISIONAL DIAGNOSIS:-

Septic shock with mild pleural effusion secondary to AKI

 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  OD