somaramreddy
Hello everyone I'm a medical intern.This blog is to share my experiences and cases I came across during this period
This is an online E log book to post and discuss our patient's de-identified health data posted after taking informed consent where we discuss patient-centered clinical problems through series of discussions among the community of experts without letting the patient move to distant places to different doctors with an aim to solve their clinical problems with the collective best evidence input from them. This online platform also reflects my patient-centered learning portfolio.
CASE PRESENTATION:
A 28year old lady name X R/O Nalgonda who is a housewife came to the hospital with the chief complaint of Chest pain since 4days and SOB since 4days.
HOPI:
The patient was apparently asymptomatic 4days back,then she developed left sided Chest pain which was insidious in onset, non progressive,aggregated with deep inspiration,no other aggregating and relieving factors,associated with palpitations,no associated sweating,no SOB on exertion.
No H/o orthopnea,PND
No H/o fever with chills and rigors
No H/o Loose stools and vomitings
No H/o pain abdomen and weakness
No H/o jaundice,no H/o blurred vision
No H/o Tb
No H/o past hospital admissions.
PAST HISTORY:
She had 2 pervious pre-term C-Sections one in 2015 (Survived for 5days)and other one in 2017(Survived for 3days), Indication: Antepartum hemorrhage.
Not a k/c/o DM,HTN,TB, Asthma, CAD, seizures.
No history of previous blood transfusions and surgery.
Marital history:
Non consanguineous marriage,married at the age of 24years,no usage of ocps.
Menstrual history:
Her cycles are regular,for every 30days she bleeds for 3-4days,normal flow.
No H/o vaginal discharge,itching, dyspareunia.
Obstetric history:
She underwent LSCS 25days back and delivered a male baby.
She is a multigravida with 2dead babies and one live baby.No still births,no tubectomy done.
2TT's given in pregnancy,No relevant history in pregnancy.
FAMILY HISTORY:
no significant family history.
PERSONAL HISTORY:
diet-mixed
appetite-normal
sleep-adequate
B&B-regular
addictions-none
GENERAL EXAMINATION:
Patient was conscious, coherent,cooperative
moderately built and nourished.
Pallor:present
Icterus:no
Cyanosis:no
Clubbing:no
Koilonychia:no
Gerneralised lymphadenopathy:no
Pedal edema:No
Vitals:
Temp:pt.is afebrile
PR: 78bpm,regular in rhythm,no Radioradial delay,no radiofemoral delay
RR: 18cpm
BP: 110/80mm Hg in Right arm in supine position
Spo2 - 98%
Grbs -105 mg%
Systemic examination:
PER ABDOMEN: Soft , non tender, no organomegaly
Bowel sounds present
CVS: s1 and s2 heard , no murmurs
RESPIRATORY SYSTEM:BAE present, NVBS heard
CNS:Higher mental functions- intact
Cranial nerves- normal
Motor system-normal
Sensory system- normal
Cerebellum- intact
No signs of meningeal irritation
The following investigations were done:
Review USG Abdomen
PROVISIONAL DIAGNOSIS:PYELONEPHRITIS SECONDARY TO UTI WITH AKI,
RENAL CORTICAL NECROSIS WITH THROMBOCYTOPENIA SECONDARY TO INFECTION.
1.Tab.ULTRACET-QID
2.Tab.MET-X L 12.5mg -BD
3.Inj.OPTINEURON 1AMPULE IN 100ml NS
4.Tab.Caripill 100mg/OD
5.IV FLUIDS 1 unit NS @50ml/hr
6.Inj.PIPTAZ 2.25mg/IV/TID
7.Inj.METROGYL 500mg/IV/TID
8.Inj.PAN 40mg IV/BD
Added information:
A 28 year female in perperium( 20th day post partum) presented to opd with retrosternal pain, and with hemogram report showing low platelet count .
Retrosternal pain is increasing on inspiration and with change of position.patient also gave history of palpitations on enquiry.
No history of fever,no history of burning micturation, no history of dyspnoea,no history of bleeding manifestations.
Her first pregnancy was in 2015 ,during which she suffered abdominal pain in third month, and UTI later on for which she used medication.
She gave birth to preterm child in 8th month of pregnancy,who died on 5th day after delivery with ??congenital heart disease.she also gave history of usage of ??ring pesary.
During her second pregnancy also she gave history of UTI and usage of ?? ring pesary. Even second child died on 3rd day of delivery.( cause _ not clear)
Both the deliveries are with caessarian section
During third pregnancy ( current one) also she gave history of UTI and no usage of ring pesary.
But delivered a healthy baby currently 21 day old .
Their marriage is non consaguinous.
Now mother came to hospital with thrombocytopenia and chest pain
On examination
Pr _ 140 bpm regular
BP _ 110/70
No other significant findings on examination
Initially cause of chest pain was interpreted as costochondritis
as
1. ecg was showing only tachycardia
2. 2d echo _ normal
3. Chest x ray _normal
Cause of thrombocytopenia was interpreted as drug induced as she is using NSAIDS ( for post caessarian section pain)
and no other routine investigations were sent as patient is asymptomatic
But to rule out HELLP
LFT was sent
Which showes slightly raised bilirubin
Normal AST and ALT
raised ALP
and decresed serum albumin.
To know the case of hypoalbuminemia cue and rft was sent
CUE _ 10 to 15 pus cells
3+ albumin
Rft _ sr.creatinine _ 6.6mg/dl
Sr.urea _ 168mg/dl
Normal electrolytes
Then usg abdomen,pt inr,aptt, hiv was sent
Usg showed _ B/l pyelonephritis and retroverted uterus
Pt inr,aptt _ normal
HIV _ negative
