SHORT CASE: FINAL PRACTICAL

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.  

June 6, 2022

YOGITA AILANI

Hall ticket no:1701006002

CASE PRESENTATION:

A 45 year old lady, resident of Nalgonda, Tailor by occupation presented to GM OPD with chief complaints of 

• Fever since 3months
• Body pains since 3months
• loss of appetite since 3months
• Appearance of facial rash since 10days

HISTORY OF PRESENTING ILLNESS:

EVENT TIMELINE:

CLINICAL IMAGES:

PAST HISTORY:

Patient had a history of diminution of vision which started at the age of 15 years.
For which she was advised use of 

• To use spectacles

But there was gradual, progressive, painless loss of vision and she was diagnosed as

• Optic atrophy with macular degeneration in both the eyes.

No h/o any trauma,
Not a known case of  DM/HTN/ASTHMA/CAD /EPILEPSY/TB 

PERSONAL HISTORY:

Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- disturbed
Addictions- nil

FAMILY HISTORY:

No similar complaints in the family.

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
no signs of edema, icterus, clubbing, cyanosis, lymphadenopathy.

VITALS:

Temperature : Afebrile
Pulse rate : 72beats/min
BP : 110/70 mm Hg
RR : 18 cpm
SpO2 : 98% at room air

SYSTEMIC EXAMINATION:

CVS:

INSPECTION: shows 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.

GIT:

INSPECTION: normal scaphoid abdomen with no pulsations and scars
PALPATION: all 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 
AUSCULTATION: B/L air entry present, vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS:

? Secondary sjogren syndrome
Anemia

B/L Optic atrophy 

INVESTIGATIONS:

RBS: 136mg/dl

HEMOGRAM:

HB: 6.9
TC: 9700
MCV: 85.1
PCV: 21.7
MCH: 27.1
MCHC: 31.8
PLT: 1.57
ESR: 90
SMEAR: ANISOCYTOSIS

RFT:

Blood Urea: 20mg/dl
S. Creatinine: 1.1mg/dl
Na: 136
K: 3.3
Cl: 98

LFT:

TB: 0.45
DB: 0.17
AST: 60
ALT: 17
ALP: 138
TP: 6.3
ALB: 2.18

CUE:

ALB +
Sugars nil
Pus cells nil

ESR - 90

CRP - NEGETIVE

HCV: NEGETIVE

HBV: NEGETIVE

HIV: NEGETIVE

TREATMENT:

• Tab. Pan 40mg/PO/OD
• Tab. Deflazocort 6mg/PO/BD
• Tab. cefixime 200mg/PO/BD
• Tab. Orofex-XT (15 mins before food)/PO/OD
• Tab. Teczine 10mg/PO/OD
• Hydrocortisone cream 1%/LA/OD for 1 week (on face).

Advice:

• GRBS every 6th hourly 
• Monitor vitals.