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:







Past history:
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
Eyes proptosis present
Extra ocular muscles intact
Tongue ulcers present
Thyroid no goitre
Skin multiple hyper pigmented macules all over the face, upper and lower limbs, trunk and abdomen .skin is dry .

Thickening of skin noted over the forearms, for sum of hands and around mouth.
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
ABG
pH 7.34
PCo2 18.8
PaO2 92.4
HCO3 12.2
SpO2 96
LFT
TB 2.8
DB 0.74
AST 14
ALT 10
ALP 673
TP 7.4
ALB 2.23
CUE
ALB ++
Sugars nil
Pus cells plenty
Epithelial cells 1-2

COVID-19  - NEGATIVE

ESR - 70
CRP - POSITIVE
Chest X-ray:
ECG
USG abdomen
HRCT Chest

Both lungs studded with tiny nodular densities likely to be military TB
No evidence of effusion

Repeat HRCT on 23-3-22


Provisional diagnosis
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
Liquid paraffin all over body TID

Reference 

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