1801006078 - Short Case

 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-centred online learning portfolio and your valuable comments on comment box is welcome. 

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.

CASE

This is a case of a 65 year old female admitted in the ward, with a complaints of 

• B/L Pedal edema :- 10 days
• Facial puffiness:- 10 days
• Shortness of Breath :- 4 days
• Dry cough :- 4 days
• Fever:- 4 days

History Of Presenting illness:

Pt. was apparently asymptomatic 15 days back, then she had

•  Pedal edema and facial puffiness (since 10 days) . [No burning micturation,no decrease in urine output, no loin pain]
• She complaints of fever since 4 days which continuous and has no diurnal variation, and is associated with chills and rigor , she hasn't used any medication for it.
• Cough and Pain during coughing at B/L epigastric region.
• S.O.B since 4 days ( grade 4) 

Negative History

• No chest pains
• No complaints of Orthopnea
• No complaints of PND 
• No palpitations 

History of Past illness:

• Patient had similar of complaints of B/L Pedal edema 3 months ago , it lsted for 5 days.
• Pt. Is a known case of Diabetes Mellitus (type 2) since 30 years [using T. Metformin 500 mg po/od)
• Pt. Had Hysterectomy
• Patients had a knee joint fracture 10 years ago.
• No h/o HTN, TB , Epilepsy, Asthma.
• 
  

Personal history-

• Diet- mixed
• Apetite- decreasedl
• Seep- adequateo
• Bowel (constipated) and bladder regularo
• No Addictions

Family history

• Not significant

Allergic history

• No known allergies

General physical examination

• Patient is C/C/C.
• Pallor : no
• Icterus: No
• Cyanosis :no
• Clubbing of fingers/toes : Yes
• Lymphadenopathy : No 
• Edema of feet : Yes [ grade 3]
• 
  
  
  
  
• Malnutrition : No
• Temp. : 98.2 F
• P.R. : 92 bpm
• R.R. : 21 cpm
• B.P. : 110/70 mmhg

SYSTEMIC EXAMINATION

CVS 

• Cardiac sounds      :- S1 & S2 - Present
• Cardiac murmurs   :- NO 

RESP. SYSTEM

• Dyspnoea  :Yes
• Wheeze    :Expiratory wheeze presenting in all areas.
• Position of Trachea : Central
• Breadth Sounds : Vesicular

ABDOMEN

• Shape of abdomen : Distended 
• Tenderness : NO
• Palpable Mass : NO
• Liver : Not Palpable
• Bowel sounds: Yes

C.N.S

• Level of consciousness : Consciousness: Conscious / Alert 
• Speech : Normal
• Signs of Meningeal irritation   a)Neck stuffiness: NO  b)Kernig's sign: NO
• Cranial nerves- Normal
• Motor system - Normal
• Sensory nerves- Normal
• Glasgow Scale - 15/15
• 
  
  
• 
  

TEST REPORTS

Ultrasound of thorax and abdomen 

Impression:-

• Mild ascites
• B/L pleural effusion 

Right:- moderate
Left :- mild

                

E.c.g

          

X-Ray of chest:-

               

 

Other test results

                    

Calcium - 9.8 mg/dl

Bence Jones proteins - negative 

24 hour urinary protein - 829 mg/dl 

24 hour urine volume - 1800 ml

LDH - 302 IU/L

Pleural sugar - 143 mg/dl

Pleural protein - 0.9 g/dl 

T3 - 0.53 ng/ml

T4 - 9.87 microg/dl 

TSH - 1.93 micro IU/ml

Nurse records :-

                         

FUNDUS EXAMINATION:

RE:TRACTIONAL RETINAL DETACHMENT ON B SCAN

LE:SEVERE NPDR CHANGES NOTED[TORTUS ,ATTENUATED COTTON WOOLSPOTS+,DOT

HEMORRHAGE SUPERIOR TO DISC+,FIBROUS BANDS EXTENDING FROM DISC]

DIAGNOSTIC PLEURAL TAP:

PLEURAL FLUID ANALYSIS

PLEURAL PROTEIN -0.9/SERUM PROTIEN -5.2=0.17

PLEURAL LDH-116/ SREUM LDH-302=0.38

>2/3X460=306

SUGGESTING TRANSUDATIVE FLUID

Provisional Diagnosis:- 

ACUTE GLOMERULONEPHRITIS

TRANSUDATIVE PLEURAL EFFUSION [SECONDARY TO HYPOALBUMINEMIA?]

RIGHT EYE:TRACTIONAL RETINAL DETACHMENT [B SCAN]

LEFT EYE:SEVERE NPDR CHANGES

WITH K/C/O DM2 [30 YEARS]-HBA1C= 7.5% ON 22/11/22

TREATMENT:-

Piptaz 4.5g I.V/t.i.d

Inj. Lasix 40mg/i.v. b.d.

Tab ofloxacin 200 mg/p.o. b.d

Syp. Ascoril -D 10 ml/p.o. t.i.d 

Reference:-

Edema Grading :-https://images.app.goo.gl/CPsXaSSp7TQGvoNa7

Glasgow scale :- https://images.app.goo.gl/FKenADGMDV5UU1uA8