Final exam :Short 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.

Cheif complaints:

70 Year old female patient presented to OPD with the cheif complaints of sob since 5 days and also complaints of vomitings since morning, loose stool 2-3 episodes, complaints of Lump over left back.

HISTORY OF PRESENT ILLNESS : 

Patient apparently asymptomatic 3 years ago

Patient went to regular check up diagnosed with Hypertension and on Regular medication .          

 she was unable to do her work with grade 2 sob which was progressed to grade 4 sob 

Vomitings Since 3 days of  3-4 episodes ,food particles as a content

Complaints of Loose stools, 2- 3 episodes 

C/0 lump over left back ,tenderness present and no local rise of temperature

No orthopnea ,No PND, no chest pain,no syncopal attack, palpations present,

Complaints of decreased urine output since 10 days

No complaints of burning micturition 

No complaints of fever ,cough ,cold

No pain abdomen 

PAST HISTORY:

History of Hypertension and on regular medication since 2 years . No history Dm,Asthma, epilepsy ,TB,CAD 

 

PERSONAL HISTORY:

Diet: mixed 

Appetite : normal 

Bowel and bladder : loose stool 

No addictions 

No known allergies,

TREATMENT HISTORY:- 

Surgery done for fibriod uterus in 2006

FAMILY HISTORY - Not significant! 

GENERAL EXAMINATION:

Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing- absent

Lymphedenopathy - absent

Edema - absent

VITALS : 

Temp - afebrile

Bp -90 /60 mmhg

Spo2- 95% at room air

RR - 32cpm. 

SYSTEMIC EXAMINATION : 

Cvs - S1S2 heard,no murmurs heard

RS:Wheeze - absent

Dysponea - present

Position of trachea - central 

Breath sounds - normal vesicular sound heard 

Adventitous sounds - basal crepts heard 

P/A : 

obese abdomen ,soft and non tender 

CNS : 

NAD

ECG:on 5/2/2022

ECG on 6/2/2022

Chest Xray:

USG abdomen:

USG chest:

2D echo

Provisional Diagnosis: 

An Intriguing case of septic shock

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