This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
A 30 year old female completed her degree final year came with
Chief complaints : Fever since 2 month’s and cough with sputum since 15 days.
HOPI:
Patient was apparantly assymptomatic 2 months back and then she developed fever which was insidious in onset,high grade and not associated with chills and rigors and relieved on taking medication and again after one week she again developed fever which is of high grade and 15days back patient developed cough associated with sputum.And her sputum is scanty in amount,white in colour,no blood in sputum and non foul smelling sputum.And patient developed shortness of breath which is present only at nights not disturbing her sleep and she had known about it after her attenders noticed it.SOB at nights only since15 days which is on and off and 15days back diagonosed to be having pericardial effusion.
No loss of Apetite,No weight loss in last 2 months.
Past history :
Not a known case of DM,HTN ,TB, ASTHMA, CAD and CVA.
Attendend a weight loss programme for which she lost 7kgs in last 7 mnths.
General examination:
No pallor,Icterus,Cyanosis,Clubbing,Koilonychia,Lymphadenopathy and edema.
JVP:No raise
RR: 18cpm
Bp:110/70 mmhg
PR:85bpm
Systemic examination:
CVS:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsation
Palpation :
Apex beat can be palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
Auscultation :
- S1,S2 are heard
- Decreased heart sounds
Respiratory:
Inspection:
Trachea appears central
No visible scars, sinuses, engorged veins
Chest is bilaterally symmetrical and moves symmetrically which inspiration
Palpation:
Inspectory findings are confirmed on palpation
No local rise in temperature and no tenderness
Percussion:
Dull note is heard on percussion in infra axillary and infrascapular area
All other areas are resonant on percussion
Auscultation:
Air entry decreased in right side
Right infrascapular wheeze and right infraaxillary wheeze and left Infrascapular crepts are present.
Bilateral air entry is present
CNS:
The patient is conscious.
No focal deformities.
cranial nerves - intact
sensory system - intact
motor system - intact
Investigations:
Temperature:Afebrile at time of presentation
Mantoux test:Done outside shows positive reaction.
CB NAAT of sputum:Shows negative for AFB
Chest x ray
Pericardial fluid ADA levels raised :61
Pericardial fluid for CB NAAT:No AFB and no sensitivity for rifampicin
PROVISIONAL DIAGNOSIS:
pericardial effusion secondary to TB.
Treatment:
1)Anti tuberculosis drugs 4pills/day
2)Tab Wysolone 20mg PO BD for 3 days followed by Tab Wysolone 20mg PO OD for 2 weeks
3)Neb.Budecort 1 respule 6th hourly.
Comments
Post a Comment