5/10/21
45YR FEMALE WITH FEVER, VOMITINGS AND SHORTNESS OF BREATH
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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 Vomitings since 4 days
C/O Headache since 4 days
C/O Shortness of breath since 2 days
Patient was apparently asymptomatic 5 days back then he developed fever (Sudden in onset gradually progressive ) not associated with chills and rigor, no diurnal variations, no Sweating.
C/O Vomitings Since 4 days (non bilious), non- projectile,food particles as content
C/O shortness of breadth (grade 3) according to NYHA classification, no orthopnea, no PND, no Palpitations.
C/O B/ L Pedal edema (Since Yesterday) Pithing type, not associated with decreased Urine output.
K/C/O HTN Since 4 Months (unknown Medication)
C/O loss of appetite
C/O On and off fever Since One month (low grade).
No H/O weight loss
Not a k/C/O DM/ TB / epilepsy / Thyroid.
Personal History.:
Married
Occupation:
Appetite: DECREASED
Diet: Mixed
B&B : Regular
No Addictions
Menstrual History:
Age of Menarche :
cycles:
Family History:
On General Physical Examination:
pt is C / C / C, .
Pedal Edema - Present - B/L
JVP: Raised .
Cervical lymph nodes - enlarged
No signs of pallor, icterus, cyanosis, clubbing .
Vitals:
Afebrile
PR: 100 bpm
RR: 16 Cpm
BP: 110 / 70 mm Hg
SPO2: 99% at RA
CVS: S1, S2+
RS: BAE +, Rt sided expiratory crepts + at SMA & IMA.
P/A: Soft , NT, BS +
CNS: NAD.
Investigations:
30 / 09 / 21: X-ray chest PA and Lateral view: Right upper lobar Pneumonia with consolidation in posterior basal Segment above the oblique fissure.
On 01 / 10 / 21:
2d ECHO: EF: 58%, Mild MR+ / AR +, Mild to moderate TR+ with PAH, NO RWMA, No AS/MS, Sclerotic AV, Good LV systolic function, Diastolic dysfunction +, NO PE.
USG Neck :
Goji Berries... yes... I tried those too.For my health conditions, Those sweet, red berries seemed to help, but only during the time when I consumed them. I don't want to take a drug for the rest of my life, so why would I want to take a natural supplement everyday for the rest of my life (although Goji berries are very tasty and are highly nourishing). To me this was not a cure either (and I'm LOOKING for the CURE).
ReplyDeleteUp to that point, I hadn't found a cure. I felt like a young jumbled mess. I continued to have extreme pain, but continued on my path to healing. I started to focus on myself and not everyone else. When I was a young adult, I took on too much responsibility out of a sense of obligation. This was no longer healthy for me, so I resigned from all my projects and groups. Those days to come were the best [and worst] days. I took a lot of time off work, yet began to feel so extremely exhausted. Many health professionals "diagnosed" me with adrenal fatigue & Hiv,Prostate Cancer so my situation was annoying then I keep searching for permanent cure online that's when I came to know of Dr Itua herbal center hands whom god has blessed with ancestral herbs and a gift to heal people with diseaseSo I made a purchase of his herbal medicines and I have been watching my health for 6 years now and I actually confirmed that his herbal medicines are a permanent cure and I'm so happy that I came to know of his herbal healings.You can contact Dr Itua herbal center Email: drituaherbalcenter@gmail.com www.drituaherbalcenter.com if you went through exactly what I go through in terms of health conditions because to be honest there is more to learn about natural herbs than medical drugs.