48 yr old female with Multisystem Involvement.
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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 cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
29-03-2022
A. Vishal, Roll no -148
CASE :
A 48 year old female, resident of Hyderabad, home maker by occupation, presented to the casualty on 14-03-22 with the 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.
Personal history
- Decreased appetite
- Weight loss present
- Adequate sleep
- Regular bowel and bladder movements
General examination
Patient was examined in a well lit room, after adequate exposure and taking consent.
- Patient was conscious, coherent and cooperative. She was well oriented to time, place and person.
- Pallor - Present
- Cyanosis, clubbing, icterus, lymphadenopathy - Absent
- Edema - mild, non pitting type, extending upto feet.
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.
Systemic examination :
Respiratory system -
- Inspection : Movements of chest appears to be Equal on both sides.
- Palpation : Vocal fremitus decreased in left mamary , ISA area.
- 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.
Cardio vascular system :
- S1,S2 heard.
- No murmurs. No palpable heart sounds.
Per abdomen -
- Soft, no organomegaly.
- No guarding, rigidity.
- Bowel sounds present.
Central nervous system :
- No focal neurological deficits.
- Gait - Normal
- Rhombergs - Negative
Investigations -
RBS: 70mg/dl
HbA1c : 6.8%
RFT
Blood Urea: 136mg/dl
S. Creatinine: 4.8mg/dl
Na 139
K 3.0
Cl 102
Hemogram
HB 7.2
TC 15,000
MCV 80.4
PCV 21.5
MCH 27.0
MCHC 33.6
PLT 3.67
RDW 62
Peripheral smear - NORMOCYTIC, NORMOCHROMIC
Serum iron : 45ug/dl
ABG
pH 7.34
PCo2 18.8
PaO2 92.4
HCO3 12.2
SpO2 96
LFT
TB 2.8
DB 0.74
AST 14
ALT 10
ALP 673
TP 7.4
ALB 2.23
CUE
ALB ++
Sugars nil
Pus cells plenty
Epithelial cells 1-2
COVID-19 RAT - NEGATIVE
ESR - 180
CRP - POSITIVE (1.2 mg/dl)
RA FACTOR - NEGATIVE .
LDH - 326 IU/L
CT-SCAN-
Few small volume mediastinal lymph nodes noted
- Both lungs are studded with tiny nodular densities - miliary TB or ILD?
- Small air filled cyst noted left lower lobe.
- No evidence of effusion.
- Non-obstructive left renal calculus.
Reference :-https://karnativaishnavi.blogspot.com/2022/03/48-year-old-women-with-multi-system.html My teammates:- 
