48 year old female with shortness of breath and dysphagia
Medicine prefinal case discussion
31-2-22
M.Srilekha. roll.no:77
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
Chief complaints:
A 48 year old female resident of Hyderabad who is home maker presented on 14-3-22 with chief complaints of
shortness of breath since one week initially grade 2 progressed to grade 4
Pedal edema since one week
Chest tightness since one week
Generalised weakness and fatigue since one week
Difficulty in opening mouth
Difficulty in swallowing both solids and liquids
Clinical images: on 25th January
Present clinical findings:
Known case of hypertension since 10years and in regular medication.
K/c/o diabetes since 6 months
Hypothyroidism since 8 years and on regular medication.(THYRONORM 50mg)
Confirmed case of tuberculosis 3 months back
Personal history:
Diet:mixed
Loss of appetite and weight loss present
Sleep:adequate
Bowel and bladder:regular
No addictions
No known drug or food allergies.
Family history:
No known case of TB in the family.
General examination:
Patient is conscious coherent and cooperative
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.Patient is moderately built and nourished.
Pallor -present
No Icterus,Cyanosis,Clubbing,Lympgadenopathy
Mild edema extending up to the feet ( non pitting type)
Vitals
Pulse rate:82bpm
Blood pressure:140/90mmHg
Respiratory rate:18cpm
Temperature afebrile
Spo2:98% at room air
Head to toe examination
Alopecia present
Extra ocular muscles intact
Tongue ulcers present
Skin multiple hyper pigmented macules all over the face, upper and lower limbs, trunk and abdomen .skin is dry .
Slight peeling of skin noted over the limbs
Systemic examination:
Respiratory system:
Inspection;
Shape of the chest: bilaterally symmetrical
Position of trachea : central
Movements of the chest appears to be equal on both sides
No scars
No sinuses
Palpation:
Trachea central in position
Apex beat at 5th intercostal space in mid clavicular line
Movements decreased on left mammary and inter scapular area
Vocal frites decreased.
Persuasion : dull note on left mammary and interscapular area.
Auscultation:
Decreased air entry on left side and
Corse crepitations heard in inter scapular area more on left side , no variation with cough.
CVS:
S1 and S2 heart sounds heard
No murmurs
Perabdomen:
Soft and non tender
Not palpable liver or spleen
Bowel sounds heard
CNS:
HMF normal
Cranial nerve examination normal
Motor system
Power Rt. Left
gluteus. 3/5. 3/5
Hamstrings. 4/5. 4/5
Quadriceps. 4/5. 4/5
Investigations:
RBS: 70mg/dl
HbA1c : 6.8%
RFT
Blood Urea: 136mg/dl
S. Creatinine: 4.8mg/dl
Na 139
K 3.0
Cl 102
Hemogram
HB 7.2
TC 15,000
MCV 80.4
PCV 21.5
MCH 27.0
MCHC 33.6
PLT 3.67
RDW 62
P.S NORMOCYTIC, NORMOCHROMIC
Serum iron : 45ug/dl
ECG
Both lungs studded with tiny nodular densities likely to be military TB
No evidence of effusion
Repeat HRCT on 23-3-22
Systemic sclerosis, military tuberculosis k/c/o hypertension , diabetes mellitus -2,hypothyroidism
Dysphagia secondary to ATT induced SJS
Treament;
IVF NS/RL/DNS @ 75 ml/hr
Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins
NEB. Ipravent 1resp inH TID
NEB. BUDICORT 1RESP INH TID
INJ. HUMAN ATRAPID according to sliding scale
Inj. PIPTAZ 2.25 gm IV TID
T. Thyronorm 50 mg PO OD
INJ. PAN 40 MG IV OD
T. AMLONG 5 MG PO OD
MUCOPAIN JEL L/A 40 MINS BEFORE MEAL
Betadine mouth wash TID
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