1701006012 CASE PRESENTATION
LONG CASE
A 45 year old female , tailor by occupation came to the hospital with chief complain of
- On and off fever with generalized body weakness
- loss of appetite since 3 months
- itchy facial rash since 5-6 days
History of Presenting Illness
* Patient was apparently asymptomatic 10 years back when she devedoped joint pain which gradual was gradual in onset and of fleeting type whoich was associated with morning stiffness which usually used to lasy for 10 mins and was not associated with swelling .
- Patient went to some private hospital where she undergone some tests and and was found to be RA positive and was treated for the same for two months .
* Patient remained asymptomatic after being treated and since 8 months back when she developed joint pain in the interphalangeal joint and knee joint following injection of 1st dose of covishield . She was treated with Inj. Diclofenac for 5-6 days and pain releived in 20 days .
* One month back patient had an episode of loss of consciousness with cold peripheries and sweating after taking Tablet Glimi M2 prescribed by the doctor for her high sugar level ( around 250 mg /dL ) .
* 10 days back patient developed fever and abdominal pain for which she was treated at a private hospital .
- Later she developed an erythematous rash over the face which was associated with itching ( increased on sun exposure)
Lesion was describe as diffuse erythematous and hyperpigmented papules ans pustules were noted over the bilateral cheeck sparing the nasolabial fold . ( Drug rash ? )
* Swelling of the left leg over the lateral aspect with erythema and local rise of temperature (? Cellulitis )
Past History :
* Patient had a history of diminution of vision at age of 15 years started using sectacles but there was gradual, progressive, painless loss of vision was diagnosed as Optic atrophy with macular degeneration .
- Not a known case of DM , asthma , TB , COPD , epilepsy .
- No relevant drug, trauma history present.
- No similar complaint in the past
Personal History :
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- disturbed
Addictions- nil
Familar History :
Patient's sister had a similar history of joint pain in the past .
General Examination :
Patient is conscious coherent cooperative and well-oriented with time, place, and person
Moderately built and nourished
Pallor +
no icterus
No cyanosis
No clubbing
no lymphadenopathy
No edema.
VITALS:
Patient was afebrile at the time of presentation .
BP: 110/70 MMHG, B/L
PR: 72BPM, regular and normal volume,felt bilaterally
RR:18 CPM
SpO2 : 98 with RA
LOCAL EXAMINATION:
left lower limb swelling was present at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt.
SYSTEMIC EXAMINATION
CVS
Inspection:
no scars on the chest
no features of raised JVP no additional visible pulsations seen
Palpation
all inspectory findings are confirmed
apex beat normal at 5th ics medial to mcl
no additional palpable pulsations or murmurs
percussion showed normal heart borders
auscultation S1 S2 heard no murmurs or additional sounds
CNS: C/C/C
MOTOR-: normal tone and power
reflexes: RT LT
BICEPS ++ ++
TRICEPS ++ ++
SUPINATOR ++ ++
KNEE ++ ++
SENSORY :
touch, pressure, vibration, and proprioception are normal in all limbs
sensations could not be assessed at lt ll [dressing]
GIT:
inspection- normal scaphoid abdomen with no pulsations and scars
palpation - inspectory findings are confirmed
no organomegaly, non tender and soft
percussion- normal resonant note present, liver border normal
auscultation-normal abdominal sounds heard, no bruit present
RESPIRATORY:
inspection: normal chest shape bilaterally symmetrical, mediastinum central
no scars, Rr normal, no pulsations
palpation: Insp findings are confirmed
percussion: normal resonant note present bilaterally
Related Images
Reports :
US abdomen
US scannof whole abdomen
Raised RA factor
Raised SGPT and SGOT
Special tests
Normocytic hypochromic ( Hb 6.0 )
Mild decrease in Platelet count
Relative monocytosis
HsbAg 
Fig : ANA report
PROVISIONAL DIAGNOSIS:
? Secondary sjogren syndrome
Anaemia secondary to chronic inflammatory disease
with Left Lower limb cellulitis
B/L Optic atrophy
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SHORT CASE
71 year old male with breathlessness
Chief complaints-
A 71 year old male ,Mason by occupation came to the general medicine OPD on 1st June,2022 with chief complaints of
. breathlessness since 20 days
.cough since 20 days
.fever since 4 days
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.
71 year old male with breathlessness
Chief complaints-
A 71 year old male ,Mason by occupation came to the general medicine OPD on 1st June,2022 with chief complaints of
. breathlessness since 20 days
.cough since 20 days
.fever since 4 days
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.
71 year old male with breathlessness
Chief complaints-
A 71 year old male ,Mason by occupation came to the general medicine OPD on 1st June,2022 with chief complaints of
. breathlessness since 20 days
.cough since 20 days
.fever since 4 days
Daily routine-
He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.
History of present illness-
Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1) and dry cough.
=>2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.
=>20 days back breathlessness was progresses to MMRC grade-2 to 3
.Associated with wheeze
.Aggrevated on cold exposure,exertion
.Relieved on rest
.No orthopnea and PND
=>20 days back,he developped cough with expectoration
.Mucoid in consistency
.Non foul smelling
.Non blood stained
.Aggrevated at night
=>4 days back,he developped fever,which is continuous and low grade
.Evening rise of temperature is present
.Relieved on medication
.Not associated with chills and rigors
History of past illness-
.No history of similar complaints in the past
.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.
Personal history-
.Diet-mixed
.Appetite-decreased since 2 months
.Sleep-adequate
.Bowel movements-regular
.Bladder movements-decreased flow of urine since 15 days associated with burning sensation
Addictions-smoking since 2yrs (4 beedies per day)
Drinks toddy from 22yrs of age (1 litre per day)
.Stopped smoking and alcohol intake since 2 months.
Family history-
.No history of similar complaints in the family members
General examination-
Patient is conscious, coherent , cooperative.well oriented to time, place and person
He is thin built and moderately nourished.
.Weight-34 kgs
.Temperature-99°F
.Pulse rate-83 beats per minute
.Respiratory rate-20 cycles per minute
.BP-120/80 mm of hg
.SpO2-95%at room air
.GRBS-108mg/dl
.Pallor- absent
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- absent
Systemic examination-
Respiratory system-
Inspection-
.Shape of chest-bilaterally symmetrical,elliptical
.Trachea- shift to right side
.Chest movements-decreased on right side
.No kyphosis and scoliosis
.No crowding of ribs
.No scars,sinuses,visible pulsations,engorged veins
.No usage of accessory muscles
Palpation-
.All inspectors findings are confirmed
.No local rise of temperature and tenderness
.Trachea-shift to right side
.Chest movements- decreased on right side
.Chest expansion-decreased on right side
.AP diameter-
.Transverse diameter-
Percussion-
.Dull note heard on right upper part of chest
.vocal fremitus-equal on both sides
Auscultation-
.Normal vesicular breathsounds heard
.Decreased breath sounds on right upper lobe
.crepitations present on right mid axillary area
CVS-
.S1 and S2 heard
.No murmurs
Per abdominal examination-
.Shape of the abdomen- scaphoid
.Hernial orifices- normal
.Soft,non tender,no organomegaly
.Bowel sounds- heard
CNS-
.Speech- normal
.cranial nerves- normal
.Motor system- normal
.Sensory system- normal
.Reflexes-normal
.Gait- normal
Provisional diagnosis-
Right lung upperlobe fibrosis
Investigations-
CBP-
CUE
LFT
2D echo
HRCT
ECG
HIV
Hepatitis C
AFB culture
RFT-
.Urea-31 mg/ dl
.Creatinine-0.9
.Uric acid-3.1
.calcium- 10
.phospate-3.3
.sodium-128
.chlorine-95
.potassium-4.2
ABG-
.pH-7.44
.pCO2-34.3
.pO2 -68.3
.HCO3-23.4
.Needle thoracocentasis was done on 5 th June,2022.
.Under ultrasound guidance
.Fluid aspirated was 20 ml
.Straw coloured
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
>2/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 102 bpm
RR-26 com
SpO2-90% on RA
98% on 2 lit oxygen
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
=>03/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 89 bpm
RR-26 com
SpO2-96% on RA
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
04/06/2022-
O/E - patient is conscious, coherent, cooperative.
Temperature-98.7°F
BP-120/80 mmHg
PR- 94 bpm
RR-14 com
SpO2-92% on RA
96% on 2 litres oxygen
Respiratory system examination-
Bilateral air entry- present
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
05/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 90 bpm
RR-24 com
SpO2-96% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
06/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
07/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
Final diagnosis-
Right lung upperlobe fibrosis
