1801006157-SHORT CASE

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I have 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 diagnosis and treatment plan.

1801006157

CASE:

A 30 year old female completed her degree final year came with complaints of fever since 2 month’s and cough with sputum since 15 days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparantly assymptomatic 2 months back and then she developed fever which was insidious in onset,high grade and not associated with chills and rigors and relieved on taking medication and again after one week she again developed fever which is of high grade and 15days back patient developed cough associated with sputum.And her sputum is scanty in amount,white in colour,no blood in sputum and non foul smelling sputum.And patient developed shortness of breath which is present only at nights not disturbing her sleep and she had known about it after her attenders noticed it.SOB at nights only since15 days which is on and off and 15days back diagonosed to be having pericardial effusion.

No loss of Apetite,No weight loss in last 2 months.

Not a known case of DM,HTN ,TB, ASTHMA, CAD and CVA.

Attendend a weight loss programme for which she lost 7kgs in last 7 mnths.

Her weight is now 66kgs.

PAST HISTORY:

No history of Hypertension,Diabetes mellitus, Asthma, Epilepsy, Tuberculosis,Coronary Artery disease.

PERSONAL HISTORY:

Diet: Mixed(eats meat once in a week)

Appetite: normal 

Sleep: adequate

Bowel and bladder movements: normal

No addictions

No allergy

TREATMENT HISTORY:-

No significant treatment history

FAMILY HISTORY:-

No significant family history

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative

Well oriented to time, place and person.

No pallor,Icterus,Cyanosis,Clubbing,Koilonychia,

Lymphadenopathy and edema.

VITALS:-

Temperature:Afebrile

Blood pressure:130/80mmHg in right arm in sitting posture

Pulse Rate:120bpm,regular rhythm,normal volume

Respiratory Rate:18 cycles per minute

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Examined under adequate light

INSPECTION:

Shape of chest is elliptical 

Chest is symmetrical in position

Trachea is central

No scars,sinuses,engorged vein

Palpation:

All inspectory findings are confirmed

No local rise of temperature 

no tenderness

Chest expands more on the left side when compared to the right side 

Percussion:

Stony dull sound on percussion in right infrascapular and right infraaxillary.

Auscultation:

Right infrascapular wheeze and right infraaxillary wheeze and left Infrascapular crepts are present.

ABDOMINAL EXAMINATION :- 

INSPECTION:

Flat shaped, free flanks , umbilicus central and normal in shape, hernial orifices normal

PALPATION:

 Abdomen is soft and non tender, no hepatomegaly, no splenomegaly 

Kidneys not enlarged

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent

AUSCULTATION:

Bowel sounds – normal 

No bruits

CVS:

INSPECTION:

Chest wall symmetrical

Trachea central 

PALPATION:

Apical impulse felt 

Thrills absent

PERCUSSION:

No abnormal findings

AUSCULTATION: 

S1, S2 heard

No murmurs

CNS:

No focal neurological deficits

INVESTIGATIONS:-

Mantoux test:Done outside shows positive reaction.

CB NAAT of sputum:Shows negative for AFB

CHEST X-RAY:-

PROVISIONAL DIAGNOSIS:

pleural effusion secondary to TB.

Renal Function Tests:

Urea-19 mg/dL

Creatinine-0.7 mg/dL

Uric acid-3.0 mg/dL

Calcium -10.1 mg/dL

Phosphorous-4.1 g/dL

Sodium-134 mEq/L

Potassium-3.8 mEq/L

Chloride-100 mEq/L

Liver Function Tests:

Total Bilurubin-# 1 20 mg/dL

Direct Bilurubin-# 0 31 mg/dL

SGOT(AST)-# 45 IU/L

SGPT(ALT)-27 IU/L

ALKALINE PHOSPHATE-# 198 IU/L

TOTAL PROTEINS -80 gm/dL

ALBUMIN-# 3.19 gm/dL

AIG RATIO-66

Hemogram:

Hemoglobin-8.5 gm/dL

Total Count-7100 cells/cu. mm

Neutrophils-66%

Lymphocytes-22%

Eosinophils-2%

Monocytes-10%

Basophils-0%

PCV-27.2 vol %

MCV-72.5 fl

MCH-22.5 pg

MCHC-31.3%

RBC Count-3.72 millions/ cu. mm

Platelet Count-3.64 lakhs/cu. mm

TREATMENT:

1)Anti tuberculosis drugs 4pills/day

2)Tab Wysolone 20mg PO BD for 3 days followed by Tab Wysolone 20mg PO OD for 2 weeks

3)Neb.Budecort 1 respule 6th hourly.