1801006036-short 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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

A 47 year old female .  Homemaker        by occupation. resident of    nalgonda.came to the opd with a cheif complaint of pedal edema since 15day

Shortness of breath since 15 days

cough since13 days

fever since 3 days

History of presenting illness 

patient was apparently asymptomatic

15 days back she developed pedal edema which was insidious in onset initially edema is seen till ankle which is pitting type and Then gradually progressed to knee .

15 days back then she developed SOB which was insidious onset  a from last 12 days(grade 2 to grade  3 sob) and relived on rest for which she went to hospital and her hemoglobin levels found 3% and was advised for blood transfusion .since 4 days sob has reduced to grade 2

she developed cough since 12 days which productive in nature, yellowish white sputum no blood stain,non foul smelling

fever since 3days  associated with chills and rigor

no history of weigh loss

no history of malaise 

she noticed left side facial puffyness after 2 hr it reduced spontaneously

no abdominal distention

 NoPalpitations 

No Paresthesia in hand

No Loss of taste

Past History 

from last 1 year there is pedal edema which is on and off

no history of diabetes, asthama,Hypertension, TB,thyroid and Epilepsy 

Menstrual History 

she attained menarchy at the age of   

earlier she used to have regular 30 days Menstrual cycle with 3 days flow ,no clots

from 22march,2022 she is having regular 20 days cycle ,heavy Menstrual bleeding for 5 days for which she went to hospital and was diagnosed by fibroid uterus and was advised for hysterotomy because of her low hb level surgery was not done.she under went blood transfusion later her Hb was found to be 8gm% which was not adequate for surgery

Since  last 6 months spotting is seen for every 15 to 20 days of cycle

Personal history 

Normal appatite 

Mixed diet

Adequate sleep

Regular Bowel and Bladder movement 

No addictions 

No allergies 

Daily routine-she wake up at 5 am does daily  work(sweeping,washing cloths)then she will have a glass of milk  at 12 pm she will have rice ,dal and curry then she will have sleep for a hour 

Watch TV for 1 to 2 hr then at 9pm she will have dinner(chapati and curry)

Sleep at 10 pm

diet history 

1 glass milk-129 cal,8g

Lunch-rice 2 cups-414 cal,6.6g

            Curry 1 cup -80cal,6g

             Dal 1 cup -89cal,7g

Milk 1 glass -129 cal,6.6 g

Dinner-chapatti2 and half-172 cal,8g

             Curry-80 cal,6

Total -59.6 g and 1091 cal

She is deficit of 1509 cal

Family history 

No History of similar complaints in the family 

Treatment history 

Medroxy progesterone  acetate-once daily for 2 month

Dexorange from last 4 days

General examination 

Patient was consious, coherrent and co-operative. Well oriented with time place and person. Well built and nourished 

Pallor 

B/L pedal edema

No icterus 

No clubbing

No cynosis

No generalized lymphadenopathy 

Vitals

Pulse-114

BP 120/70

Respiratory rate-19cpm

Spo2-96%

Temp-afebrile 

Jvp raised

Systamic examination 

Jvp raised

Parasternal heave

S1 and s2 heard No murmurs 

Rs-  Trachea central

Normal vesicular breath sounds heard 

Right infrascapular wheez

Per abdomen-

INSPECTION: abdomen :round 

Moves with respiration

No abdominal distension 

Umblicus is central and inverted 

No engorged veins

No scars and no sinsus are seen

Hernias orifices are clear.

PALPATION:

All inspectory findings are confirmed 

No tenderness in the abdomen

 PERCUSSION:No significant fingings

AUSCULTATION: Bowel sounds heard 

No bruits.

Cns-no focal neurological deficit 

CILNICAL IMAGES

Provisional diagnosis-dimorphic anemia with right heart failure

Investigations 

Hb-3.6           

Mcv-73.5

MCH-17.1

MCHC-23.2

RBC COUNT-2.11

PERIPHERAL SMEAR-anisopoiklocytosis with macrocytes and microcytes,tear drop cells

Platelet adequate

SERUM IRON-42ug/dl

Treatment 

PRBC transfusion 

Inj LASIX 20mg before and half way of transfusion

Inj LASIX 40 mg iv BD

Nebulization budecort buocin