36 yr old female with SOB

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

 Our 36 yr old female came to the opd with chief complaints of 
1.Shortness of breath since 2 hours 
2.fever with chills and rigours.& Headache.since 4 days.
HOPI:-
Patient was Apparently asymptomatic 4 days back then she developed fever with chills &rigours,headache.Then she was having Shortness of breath since 2 hours .She was suffering from diarrhoea since 3 days.she also had burni
PAST HISTORY:-
S/O mastectomy (left)1 1/2 yr back 
H/O renal calculi,7 year back.
N/H/C/O- HTN,DM,Thyroid,CAD,TB, Epilepsy.
SURGICAL HISTORY:-
S/P LEFT MASTECTOMY UNDER GA
Done on (25-09-2019).
EXAMINATION:-
CVS:s1,S2 +
Resp:-BAE +
P/A:- soft ,non tender 
Investigation:-
USG -NECK-
Findings:-
Few enlarged lymphnodes noted in B/L levels 1,2 largest @8mm in SAD.
Few with hilum ,few without hilum.
On 13-8-2022:
Temp- 102 f
Bp- 90/60
PR-112/min
Cvs- S1,S2+
RS- BAE+
ABD- soft non tender 
On 14-8-2022
Temp- 104f
Bp- 100/70mmHg
PR- 94 bpm
RR- 16cpm
RS- NVBS,BAE+
CVS-S1,S2+
P/A- soft ,non tender 
On 15-8-2022
Temp-101f
BP- 90/60mmHg
PR- 112bpm
RR-18cpm
Cvs- S1,S2+
P/A- soft,non tender.
On 16-8-2022
Temp- afebrile
Bp- 110/70mmHg
PR- 70 bpm
RS : B/L AE +,NVBS
P/A :- soft ,non tender
CNS:-NAD
On - 17-8-2022
Temp- afebrile
Bp- 130/70mmHg
PR- 80bpm
RR-24 cpm
Cvs- S1 S2+,NAD.
R/s- B/l AE +,NVBS
P/A soft ,non tender
On -18-8-2022
Temp- Afebrile
Bp-130/80mmHg
RR-24 cpm
PR-76bpm
Cvs-s1 S2+
R/s - b/l AE +,NVBS
P/A soft,non tender.
On-19-08-2022
Temp-Afebrile
Bp-130/80mmHg
PR-74bpm
Cvs-s1,S2 +
R/s -BAE+,NVBS
P/A-soft,non tender 

PROVISIONAL DIAGNOSIS:-
Fever with lymphadenopathy under evaluation.

TREATMENT:-
IVF 100ML NS OPTINEURON.
INJ NEOMOL1gm/IV/sos 
INJ.IRON SUCROSE 200 mg IV/OD
TAB .NITROFURANTOIN 100mg/po/BD
TAB PAN 40mg/PO/OD
TAB.OROFER PO/OD
TAB.DOLO 650MG
TAB .CHYMEROL FORTE PO/BD
Previous Report on 25-09-2019.
DISCHARGE SUMMARY (25-09-2019).


SURGICAL ONCOLOGY REFERRAL:-

ECG:-

USG -NECK

2dECHO-

17-08-2022

17-08-2022
On 18-08-2022

On 15-08-2022


18-08-2022
COURSE IN THE HOSPITAL:-
A 36 year old female presented to the general medicine ward with above mentioned complaints. On admission initial examination was done and hemogram was done. HB was 5.5, TLC 9000 , RBC 3.74, platelet 2.42. cue was done serum creatinine: 1, sodium:138, potassium: 4.3 chlorine 99.LFT and RFT was done. she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte,inj iron sucrose 200mg IV which was uneventful. On day 2 hemogram was done hb 5.8, TLC 8400, RBC 4.01, platelet 3.53.she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte, inj. Lasix 20mg IV SOS if breathlessness occurs. On  day 3 HB was 6.4, tlc 9400, RBC 4.28, platelet 4.4 on cue blood urea was 14, creatinine 1, sodium 135, potassium 4.4, chlorine 99. she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg,tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte,. on  day 4 she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte,inj iron sucrose 200mg IV which was uneventful. on day 4, her hemogram was done and HB 6.4, TLC 7800, RBC 4.13, platelet count 5.29.she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte,inj iron sucrose 200mg IV which was uneventful. At present she is hemodynamically stable.on day 6 ,she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte,INJ.Sucrose 200mg IV which was uneventful.on day 7 ,she was started on IVF 10NS optineruron, tab. Nitrofurantoin 100mg, tab orofer, tab dolo 650mg, inj. Neomol 1gm IV, tab chymerol forte.
D echo was done on 16-8-2022
Findings :
No RWMA, Mild Pericardial Effusion(1.65cms,Right side), EF 60%, RVSP 35mmHg, Trivial TR and AR, No MR, Good LV Systolic function, No diastolic dysfunction.

On 17/08/2022 USG B/L Breast and axillary region showed fundings s/o - Right axillary lymphadenopathy.
Pateint condition was gradually improved ,so she has been discharged in a heamodynamically  stable condition.







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