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:

Usg-Abdomen
Review USG Abdomen


PROVISIONAL DIAGNOSIS:PYELONEPHRITIS SECONDARY TO UTI WITH AKI,
RENAL CORTICAL NECROSIS WITH THROMBOCYTOPENIA SECONDARY TO INFECTION.

Treatment given:
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

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