48 YEARS OLD FEMALE WITH MULTISYSTEM INVOLVEMENT

- March 29, 2022

MEDICAL 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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

March 29, 2022

YOGITA AILANI

Roll no:149

CASE DISCUSSION

A 48 year old lady, resident of Hyderabad, home maker by occupation, presented to GM OPD in the mid of march with

Chief complaints of :

Shortness of breath since 1 month
Difficulty in swallowing since 1 month
Pedal edema since 1 week
Chest tightness since 1 week.

HISTORY OF PRESENTING ILLNESS

EVENT TIMELINE:

CLINICAL IMAGES:

(OF MID JAN)

(PRESENTLY)

Credits : Special thanks to Dr Phaneendra (intern ) and Dr .V. Pavan kalyan(intern) for clinical images

PAST HISTORY

She was diagnosed with

HYPERTENSION 8years back- taking regular medication
HYPOTHYROIDISM 6years back- taking regular medication
Rheumatoid arthritis 6 years back(no proper reports were shown presently and no medication is been taken)
DM type-2 5 months back- not on medication
MILIARY TB 1 month back- started on ATT (stopped)

PERSONAL HISTORY

DIET: mixed

APPETITE: loss of appetite (weight loss present)

SLEEP: adequate

BOWEL AND BLADDER: regular

ADDICTIONS: nill

GENERAL EXAMINATION

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

she is conscious, coherent and cooperative, moderately built and nourished.

Pallor: present

Edema: mild, up to the feet, non-pitting type

no signs of icterus, cyanosis, clubbing, lymphadenopathy

VITALS

Temperature : Afebrile
Pulse rate : 78 beats/min
BP : 140/90 mm Hg
RR : 18 cpm
SpO2 : 98% at room air
GRBS : 105mg/dl

HEAD TO TOE EXAMINATION

Alopecia - Present
Eyes - Proptosis seen, no conjunctival suffusion
EOM - Intact
Bald, red tongue seen
No ulcers
No thyroid swelling
Skin - Multiple hyper pigmented macules seen all over face, upper limbs, neck, thigh, abdomen and upper back.
Dry skin present ; Thickening of skin over forearms, dorsum of hand and fingers and on and around mouth.
Hair is absent over the macules.
Slight peeling is still present over the arms and legs.

Credits : Special thanks to Dr Phaneendra (intern ) and Dr .V. Pavan kalyan(intern) for clinical images .

SYSTEMIC EXAMINATION

RESPIRATORY EXAMINATION:

INSPECTION: Movements of chest appears to be decreased on the left side in comparison to right side.

PALPATION: Vocal fremitus decreased in left mamary , ISA area in comparison to other areas.

PERCUSSION: Dull note in left mamary area and ISA area.

AUSCULTATION: Decreased air entry on left ISA,IMA area. Right side - normal air entry. Bilateral vesicular breathing noted. Tubular breathing heard on right inter-scapular area.
coarse crepitations - end inspiratory - no variation with cough - heard on left ISA >>right ISA.

CVS EXAMINATION:

S1,S2 heard
No murmurs. No palpable heart sounds.
PER ABDOMEN:

Soft, Non-tender
No organomegaly
Bowel sounds heard
no guarding/rigidity
CNS EXAMINATION:

No focal neurological deficits
Gait- NORMAL