a case of 18 yrs old female with complaint s of dyspnea since 20 days
A case of 18 yrs old female with complaint s of dyspnea,fever,loss of appetite, irregular menstrual history,cough,facial puffiness and bilateral pedal edema..
ROHITH SOMANI
MBBS 9th semester
roll no:127
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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 diagnosis and treatment plan.
Chief complaints::
Facial puffiness since 20days
Bilateral pedal edema since 20days
Cough since 10days
Fever since 20days
Loss of appetite since 20days
Dyspnea since 20 days
Irregular menstrual history since 2years
History of present illnesse:
Patient was apparently asymptomatic her mother noticed that she hasn't attained menarche even after 14yrs so they have visited gynaecologist after which attained menarche at age of 15yrs. She
born out of a non consanguinous marriage.
She was not a preterm child.she was born through normal delivery at home and her weight wasn't recorded after her birth
Diet history
She use to take rice and curry as her breakfast and rice with curry as her lunch
Biscuits and appalu as her snacks occasionally she use to have fruits.
She use to have chapathi or rice for her dinner.
Curry:vegetables and leafy vegetables.
But after her onset of illness she use have idli as tiffin and small quantity of rice or sometimes she may even skip that.
She is the eldest and she has 2 younger siblings, one currently in her 7th grade and the youngest in her 4th grade.
She studied till 12th grade and is planning on joining a degree college.
She complains of irregular menstrual cycles since the past 2 years - she gets her cycle once every 4 months and it last for 5 days, she complains of increased flow during these 5 days, she changes around 5 pads per day
--dyspnea since 20days which insidious onset gradual progressive from grade 2 to 3 MMRC
--loss of appetite since 20days she has complained after having food she has vomiting sensation so she refused to eat.
--fever since 20days which was low graded on and off type and was reduced after taking medication.
--cough since 10days which was non productive in nature and was not bood stained no diurnal variation.
--facial puffiness and bilateral pedal edema since 20days.
Past history::
No similar complaints in past
No history ofDM,HTN,epilepsy,TB.
Personal.history::
Appetite ::loss of appetite
Diet.mixed
Bowel and bladder..regular
Addictions-no addictions
No history of allergy to food or drug.
Family history::
There was no such similar complaints in family members
General examination::::
Patient was examined in a well light room with prior consent
Built:thin
Nousihment: malnourished
pallor-present,no icterus,no cyanosis,no clubbing ,no koilonychia ,no lymphadenopathy
Raised jvp
Vitals::
Bp .110/50mm of Hg
RR..18c/min
Pulse rate..110beats/min
Temperature:98 f
Systemic examination:::
Abdominal::
Inspection..
Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen
Palpation::
No rise in temperature
Tenderness present over epigastrium
No palpable mass
No free fluid
Liver palpable
Spleen not palpable
Percussion::
No fluid thrill
No shifting dullness
Auscultation::
Bowel sound heard
Respiratory system::
Inspection::
Shape of chest ::bilaterally symmetrical
No scars and sinus on Chest
No drooping of shoulder
Palpation::
Inspectory findings confirmed
Apex beat felt at 5th IC space medial to midclavicular line and diffuse type
Percussion;;
All the areas are resonant
Auscultation::
Normal vesicular breath sounds were heard
Cvs:::
S1,s2 heard
Parasternal heive is present
Raised jvp
CNS....
Conscious
Speech normal
Neck stiffness.no
Kernigs sign.no
Sensory system:intact
Motor system:::
Reflexes..normal
Power of LL,uL...5/5
Investigations:
Electrolytes
Na+ -136
K+ -3.5
Cl- 105
Serum creatinine- 0.4
Uric acid-1.5
Urea-13
Lft:
Total bilirubin-0.74
Direct bilirubin-0.20
AST-25
ALT-10
ALP-163
Total protein-6.5
Albumin-3.5
Albumin/globulin-1.20
Hemogram:
Hb:1.7
Total leucocyte-1600
PCV-6.7
MCV-76.1
MCH-19.3
MCHC-25.4
RDW-29.1
RBC-88000
PLT-45000
Her peripheral smear showing Microycytic hypochromic picture with tear drop cells, pencil forms, Anisopoikilocytosis
CUE:
Pus cells-2.3
Epithelial cells-2.3
Albumin-nil
Sugar-nil
Bile salt-nil
Bile pigment-nil
Specific gravity-1.010
Blood group:O+ve
APTT-33sec
PT-17sec
BT-2min
CT-5min
X ray..
ECG
2D echo
USG
Fever chart
Provisional diagnosis:
Pancytopenia
Treatment Given
1) Dolo 650mg Po / Sos
2) Inj Optineuron 1 Amp in 100ml NS / IV / OD
3) Inj Monocef 1gm IV / BD
4) One Unit Of Blood Transfusion Done On 23/02/2022
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