26 year old female with sob grade 3

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' 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."

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. 

  

Case:A 26 year old female housewife by occupation was bought to casualty with complaints of grade 3 sob since 2hours.

History of fever on and off since 15days associated with dry cough.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 15 days back and later developed fever for 15 days on and off associated with dry cough.

patient is a known case of pulmonary kochs 1 year back for which she took ATT drugs for 6months.

not a known case of diabetes, hypertension, epilepsy,cad,asthma.

HISTORY OF PAST ILLNESS:

                       There is no history of EPILEPSY/ASTHMA/CVA.

Treatment history:

patient is a known case of pulmonary kochs 1 year back for which she took ATT drugs for 6months.

not a known case of diabetes, hypertension, epilepsy,cad,asthma.

 ON EXAMINATION

SYSTEMIC EXAMINATION - 

VITALS - 

TEMPERATURE - 102f

PULSE RATE - 110 bpm

BLOOD PRESSURE - 

80/60 mmHg

RESPIRATORY RATE - 20 cpm

SPO2 - 96% @ RA

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS

RESPIRATORY SYSTEM : BAE +, Crepts + left IMA,ICA

CENTRAL NERVOUS SYSTEM : NAD

 Provisional diagnosis:Reactivation of pulmonary kochs

 Treatment

1.ivf ns @100ml per hour

2.inj neomol 1gm iv stat

3.tab dolo 650 mg po tid

4.temp charting hourly

5.grbs charting 6th hrly.

INVESTIGATIONS

Zn stain 2+afb

Culture cbnaat report