A 49 year old female with fever and shortness of breath


3rd semester 

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I have been given this case 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.


CASE SCENARIO 

A 49 year old female resident of Nalgonda came to casuality with chief complaints of 

C/O  FEVER since 10 days

C/O COUGH  since 10 days

C/O SOB  since 2-3 days

C/O decreased urine output since 1 day.


HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 10 days back and then she developed FEVER which is of incidious in onset, intermittent and is of low grade fever , subsided on taking medication.

Patient  has cough since 10 days which is associated with sputum and scanty in amount. C/O shortness of breath which is of grade 4 ( at the time of presentation) and worsening.  

Patient has H/o pedal edema since 5 to 6 months which is associated with facial puffiness. 

C/o of decreased urine output since 1 day.

HISTORY OF PAST ILLNESS:

    k/c/o 

HTN since 1 year.

-? k/c/o kidney disease 5-6 years back but not on any medications.

TREATMENT HISTORY:

  • HTN: since 1 year and is on Tab. TELMA-H (40/12.5 MG) - but is Irregular in taking medications.
  • Diabetes: no
  • Asthma :no
PERSONAL HISTORY:

  • Married
  • Occupation: muncipality worker
  • Appetite: normal
  • Bowels: normal
  • Micturition: normal
  • No known allergies 
  • No addictions.
FAMILIAL HISTORY:

  • No significant familial history 
  • No other hereditary diseases.
PHYSICAL EXAMINATION:

GENERAL EXAMINATION:

 Patient is conscious and coherent  

Moderately built and Moderately nourished

 

  • No pallor , icterus , clubbing , cyanosis., Lymphedenopathy and edema
VITALS:
  • Temperature: 98.6 °F
  • Pulse rate: 112
  • RR : 28 cpm
  • BP : 179/110 MMHG, 
  • Spo at room air:82%
  • GRBS: 187 MG%
SYSTEMIC EXAMINATION:

CVS:
  • Cardiac sounds S1 & S2 are present. 
  • No murmurs

Respiratory system: 

  • B/L inspiratory crepts all over lung fields.
  • PA: Soft , non tender


CNS : 
  •  conscious
  • No focal deformities. 

           


PROVISIONAL DIAGNOSIS:

   HFrEF secondary to? CAD ( EF - 35%) ( LAD - Akinesia). 

-? CKD ( stage 5.) 

-? Cardiogenic pulmonary edema.

INVESTIGATIONS:

HEMOGRAM : 

  • Hb: 8.2 gm/dl
  • TLC: 13,300 cells/cumm
  • PCV: 22.2 vol%
  • RBC: 2.95 million/cumm
  • PLT: 3.41 lakhs/cumm




LFT:

  • Total Bilirubin: 1.13 mg/dl
  • Direct Bilirubin: 0.24 mg/dl
  • SGOT: 34 IU/l
  • SGPT: 27 IU/ l
  • AlP: 327 IU /L
  • Total protein: 5.5 gm/dl
  • Albumin: 3.5 gm/dl
  • A/G: 1.85


 RFT:
  • UREA: 161 
  • CREATININE: 10 mg /dl
  • Na+: 130 mmol/l
  • K+: 4 mmol/l
  • CL-: 90 mmol/l


SEROLOGY : negative. 


 ULTRA SOUND :

B/L grade 2 RPD. 

Left simple renal cyst. 


ECG ON  30/09/2021

 






 


ECG ON 3/10/2021





 
TREATMENT:

 On 1/10/2021



 


On 3/10/2021




 



On 4/10/2021



 






 


 



 






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