1801006125 - 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.
A 13 year old female patient who is resident of Suryapet came to the General medicine O.P.D with chief complaints of
- shortness
of breath since 5 days
- Vomitings at night 5 days ago
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5 days back then she developed shortness of breath which was insidious in onset and gradually progressed to Grade 2.
Patient also complains of 4 episodes of vomitings 5 days ago which was non bilious , non projectile with food as content.
Patient complains of pigmentation/rash over face which was alter seen on scalp with hairloss and on trunk 3 months ago which is not associated with itching.
No history of fever, headache, abdominal pain.
PAST HISTORY:
Known case of Tuberculosis 1 year back and received 6 months of Anti tubercular therapy.
Not a known case of Diabetes mellitus, Hypertension, Asthma , Epilepsy, CAD
TREATMENT HISTORY:
History of Anti Tubercular therapy for 6 months 1 year back.
PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Decreased
Bowel and Bladder - Oliguria since 5 days, Bowel movements are normal
No Addictions
FAMILY HISTORY:
Mother was diagnosed with Tuberculosis in 2014.
ATT course was not taken completlely.
Symptoms got worse in 2022 and Passed way in 2022
BIRTH HISTORY:
First born child
2nd degree consanguinous marriage
LSCS
Father has no information about the immunization status
MENSTRUAL HISTORY:
Not attained menarche
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative and well oriented to time, place and person.
After taking consent , Patient is examined in a well lit room
PALLOR - PRESENT
ICTERUS - Absent
CYANOSIS - Absent
CLUBBING - Absent
GENERALISED LYMPHADENOPATHY
PEDAL EDEMA- PRESENT, BILATERAL , GRADE 1 PITTING TYPE
VITALS :
TEMPERATURE - AFEBRILE
BLOOD PRESSURE - 130/80 mmhg
PULSE RATE - 110bpm , Regular, Normal volume
RESPIRATORY RATE - 32cpm
SpO2 - 99% at room air
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM EXAMINATION:
INSPECTION:
CHESTWALL SHAPE - NORMAL
PRECORDIAL BULGE - ABSENT
PECTUS CARINATUM OR PECTUS EXCAVATUM ARE ABSENT
KYPHOSCOLIOSIS - ABSENT
NO DILATED VEINS ,SCARS, SINUSES
APICAL IMPULSE IS NOT SEEN
NO PULSATIONS ARE SEEN
JVP is RAISED
PALPATION:
Kyphoscoliosis is absent
Apical Impulse -NOT FELT
No pulsations felt
No thrills felt
No dilated veins felt
PERCUSSION:
Right heart border is Normal
Left Heart border - INCREASED DULLNESS ON LEFT SIDE
AUSCULTATION:
Mitral Area - s1 s2 heard, muffled heart sounds
Tricuspid area - s1 s2 heard, muffled heart sounds
Pulmonary area - s1 s2 heard, no added murmurs
Aortic area - s1 s2 heard , no added murmurs
RESPIRATORY SYSTEM EXAMINATION
Inspection -
Supra clavicular: Present Present
Infra clavicular: Present Present
Mammary: Present Diminished
Axillary: Present Diminished
Infra axillary: Diminished Diminished
Supra scapular: Present Present
Infra scapular: Diminished Diminished
Inter scapular: Present Present
Supra clavicular: resonant resonant
Infra clavicular: resonant resonant
Mammary: resonant DULLNESS
Axillary: resonant DULLNESS
Infra axillary: DULLNESS DULLNESS
Supra scapular: resonant resonant
Infra scapular: DULLNESS DULLNESS
Inter scapular: resonant resonant
Supra clavicular: NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: NVBS Diminished
Axillary: NVBS Diminished
Infra axillary: Diminished Diminished
Supra scapular NVBS NVBS
Infra scapular: Diminished Diminished
Inter scapular: NVBS NVBS
Infra clavicular: Resonant Resonant
Mammary: Resonant Diminished
Axillary: Resonant Diminished
Infra axillary: Diminished Diminished
Supra scapular:Resonant Resonant
Infra scapular: Diminished Diminished
Inter scapular: Resonant Resonant
- MONEY BAG SHAPED HEART SHADOW
- ENLARGED CARDIAC SHADOW
- LOSS OF COSTO-PHRENIC ANGLE ON BOTH SIDES
- Liver, gall bladder , pancreas , spleen , uterus , ovaries are normal.
- Mild Ascitis
- Bilateral Pleural Effusion
- Moderate Pericardial Effusion
- Bilateral Grade 2 Renal Pelvis Dilatation changes
- Sub-mucosal edema of small bowel loops
- FLUID RESTRICTION
- SALT RESTRICTION
- INJECTION LASIX 40 mg IV BD
- INJECTION MONOCEF 1gm IV BD
- INJECTION METHYL PREDNISOLONE 250mg in 100ml NS IV OD
- TAB. ALDACTONE 25mg PO OD
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