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 a diagnosis and treatment plan.
Name :- Kattekola Sathwik
Roll no :-58
2017 batch
65 years old female from rural nalgonda came with cheif complaints of fever since 10 days, shortness of breathe since 2 days
HISTORY OF PRESENT ILLNESS
The patient was apparently in her normal state of health 4 months ago.
She developed fever which was insidious in onset , intermittent in nature which was relieved on medication associated with generalised weakness
She also complaints of a chest pain on exertion
She also complains of shortness of breath grade 3 MMRC since 3 days. Associated with cough with expectoration (white sputum)
Yesterday she had a similar episode of fever high grade and continuous with chills and rigors , weakness..which did not subside on medication
PAST HISTORY:
Known case of diabetes and hypertension from 10 years
No history of CAD ,asthma , epilepsy
Surgery for breast lump 4 months ago
Hysterectomy -15 years back
PERSONAL HISTORY:
Appetite: reduced since 1 year
Diet: mixed
Sleep: adequate
Bowel and bladder : regular
Sleep: adequate
Addictions: none
Allergies: no allergies
FAMILY HISTORY: insignificant
GENERAL PHYSICAL EXAMINATION
Conscious coherent cooperative
Moderately built and Moderately nourished
Pallor: present
Icterus: no icterus
Cyanosis: no cyanosis
Clubbing: no clubbing
Generalised Lymphadenopathy: no generalised Lymphadenopathy
Pedal edema : no pedal edema
Flapping tremors seen
VITALS:
Temperature: febrile 103°F
Respiratory rate: 18cpm
Blood pressure: 100/60mm Hg
SpO2: 97%
GRBS: 96mg/dl
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Upper respiratory tract is normal
Lower respiratory tract
Inspection
Chest is bilaterally symmetrical
The trachea appears to be in centre
Apical impulse is not appreciated
Chest movements appears to be reduced on left side
No dilated veins, scars or sinuses are seen
Palpation-
(There were limitations for complete examination of the patient due to her Generalised weakness and ICU setting)
Trachea is felt in midline
Movements Decresed on left side
Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line
Tactile vocal fremitus- increased in left inframammary
Percussion-
Left inframammary - dull note
Auscultation-
Normal vesicular breath sounds are heard in the right lung
Bronchial breath sounds and increased vocal resonance in inframammary area of left inframammary area
Fine crepts in left inframammary area ,infraclavicular, interscapular area
CARDIOVASCULAR SYSTEM:
First and second hard sounds heard. No murmurs.
CENTRAL NERVOUS SYSTEM:
No meningeal signs
Higher mental functions normal
No focal neurological deficit
PER ABDOMEN:
Soft non tender
No organomegaly
Provisional diagnosis
65 year old woman with fever under evaluation with a suspicion of left lung parenchymatous lesion mostly pneumonia of unknown etiology
INVESTIGATIONS:
ABG:
pH : 7.4
pCO2: 20.1
pO2: 76.1
HCO3: 13.3
Serum HCO3: 16.9
02 Saturation: 96%
HEMOGRAM:
Hemoglobin: 8.0g/dl
Total Leukocyte count: 21600/mm³
Platelets: 4 37 lakhs/mm³
COMPLETE URINE EXAMINATION:
Albumin: positive
Sugar: nil
Pus cells: 4-5
Epithelial cells- 3-4
malaria: negative
RBS: 190mg/dl
Serum urea: 79
serum uruc acid: 7.4
serum creatinine: 2.3
Serum electrolytes:
Na+ : 134
K+ : 4
Cl- : 97
Ca+2: 9.6
LIVER FUNCTION TESTS:
Total bilirubin: 0.41
direct bilirubin: 0.13
AST: 29
ALT: 14
ALP: 166
Total protein: 5.7
Albumin: 2.31
Albumin: Globulin ratio: 0 68

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