Skip to main content

 CASE SCENARIO:-

*A 28 yrs old female came to opd chief complaints of pain at right hypochondrium, pain in the left flank, shortness of breath, tiredness(since 2 years).


HISTORY OF PRESENT ILLNESS:-

*Patient was apparently asymptomatic 15yrs ( i.e in 2007 ) she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria.


HISTORY OF PAST ILLNESS:-

*TB in 2007

*Hematuria on 25th May 2022


TREATMENT HISTORY:-

*Homeopathy for SOB.


PERSONAL HISTORY:-

*Diet is mixed.

*Appetite is normal.

*Bowel movement is regular.

*Bladder movement is normal.

*Micturition normal.

*No known allergies.

*No addiction to alcohol and smoking.


FAMILY HISTORY:-

*No H/O of HTN, DM.

*Father having gastric problems.

*Father having hernia.


MENSTRUAL HISTORY:-

*Periods are irregular since 2 months.


PHYSICAL EXAMINATION:-

*No pallor, icterus, cyanosis, clubbing.

*No lymphadenopathy.

*B.P- 110/70 mmHg

*Temperature- 98.6 F

*Pulse rate- 66per min.


PROVISIONAL DIAGNOSIS:-

*Right upper lobe fibrosis secondary to old pulmonary tuberculosis.


INVESTIGATIONS:-

#Haemogram:-

Hb-12.1

TLC-8800

N/L/E/M/B-58/34/4/4/0

MCV-85

MCH-28

PLC-1.58

#LFT:-

Total bilirubin-1.4

Direct bilirubin-0.28

AST-24

ALT-26

ALP-138

Total protein-6.8

Albumin-4.0


#RFT:-

S.Creatinine-0.7

B.Urea-29

S.electrolytes-

     Na+=141

     K+=4

     Cl-=100

#CUE:-

Sugar/Bile salts/Bile pigments/Albumin- Nil

Pus cells- 2-3

RBC/Crystals/Casts- Nil


Chest X-Ray:-


Comments

Post a Comment

Popular posts from this blog

  CASES IN GENERAL MEDICINE 41-YEAR-OLD MALE PATIENT WITH A HISTORY OF FEVER AND ALTERED SENSORIUM   Hi, I am Ankesh Kumar Sahu a medical student.  This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent.  This E-log book also reflects my patient-centered online learning profile and your valuable inputs on the comment box are 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 DISCUSSIOn CASE: - 41year old male resident of Chalakurthy p resented to the OPD in summer 2021 with c hief complaints of  Fever - Since 2 days. Altered sensorium with irrelevant talk- Since 1 day.   HISTORY OF PRES...
Post a Comment
Read more
A 45 YEAR  FEMALE WITH FEVER, VOMITING AND SHORTNESS OF BREATH 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 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. A 45year female Presented with  C/O Fever since 5 days C/O Vomiting since 4 days C/O Headache since 4 days C/O Shortn...
Post a Comment
Read more