A 19 yrs old female with SOB since 5 days

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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.

19year old female came to the casuality with the 
Chief complaints - 
✓ sob since 5 days 
✓ cough since 5 days
✓ fever 5 days 

 Patient was apparently asymptomatic 4 months back then she developed cough (non productive) on and off, aggrevated 4 days back 
C/o  vomtings since 4 months (on& off)
SOB since 4-5 days( grade 2) no h/o of orthopnea,palpatations,pnd,
H/o fever 5 days back high grade and  associated with chills and rigor
No h/o pain abdomen, loose stools,burning micturation,cold
Past history

She was taken to private hospital where she was diagnosed with left plueral effusion and left lower lobe consolidation 
Not a k/c/o HTN,DM,asthma,thyriod disorders, CAD, epilepsy,CVA

Personal history -

Diet - Mixed 

Sleep - Adequate 

Appetite - normal 

B&B - regular 

No addictions 

Menstrual history -

Menarche - 13 yrs

Menstrual cycle - 5/28

LMP - 2/1/23

Gravida - 1
 
Family history- 

No significant family history

General examination -

Patient was conscious coherent co-operative
 
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS
BP- 80/40mmhg
F/b ns@ 700ml
Bp - 90/60mmhg


PR -100 bpm

RR-22cpm

Spo2 99% at room air 

Temperature -102 f
System examination 

CVS: S1 S2 heard , jvp not raised,apex beat pounding 



RS: BAE present ,NVBS - decreased breath sound IA,IAA,IMA



CNS: NFND



P/A: Non tender,uterus just palpated





Investigations on 2/6/23


 .....


USG chest 


Antenatal scan on 2/6/23 

Review USG on 4/6/23 

Provision diagnosis -

Primi gravida with ?high output cardiac failure with severe anemia secondary to ? Nutritional?IDA with septic shock ? Hypovolemic shock with hyookalemia secondary to GI loss with left plueral effusion with left LL consolidation 

 Treatment history - 
One unit of prbc transfusion was done on
 2/6/23
1.Iv fluids NS,Rl 50ml/hr
2.Augmentin 625 po/od 
3.inj.zofer sos /iv
4.Tab. Dolo po/sos
5.inj neomol 1gm iv /sos if temp> 101.2f
6. Syp.dextromethorphan
2tsp po/TID

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