1801006078 - Short Case
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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.
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
Other test results
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:-
Edema Grading :-https://images.app.goo.gl/CPsXaSSp7TQGvoNa7
Glasgow scale :- https://images.app.goo.gl/FKenADGMDV5UU1uA8
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