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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 prognosis
A 56 year old Male resident of akkireddy gudam milk vender by occupation brought to casualty with chief complaints of :
Pedal edema since 4 weeks.
Dropping of neck since 3 days.
Shortness of breath since 2 days.
Brought to causality in unresponsive state 1 day back.
Patient was drowsy but arousable since Monday(17/04/23) evening and became unresponsive since Tuesday (18/04/23) morning and unable to talk and was brought in gasping state to ICU.
𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-
Patient was apparently asymptomatic 4 months back then he developed pain in lower back dragging type which is radiating to both lower limbs associated with difficultly in walking and was bound to chair and developed of chest pain non radiating since 4 months .
Patient was planned for MRI spine and was not done as patient was not cooperative.
History of bilateral pedal edema pitting type grade 1 since 4 weeks.
Shortness of breath since 2 days grade 4
History of fever since 1 day continues high grade not associated with cough.
History of gradual loss of weight since 4months due to decreased appetite
history of bowel and bladder incontinence.
No H/o decreased or increased urine output.
No H/o nausea,vomiting.
𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐀𝐒𝐓 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-
Not k/c/o HTN,DM,TB, EPILEPSY,CVA,CAD.
Family history:- not significant
𝐏𝐄𝐑𝐒𝐎𝐍𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-
Appetite:- decreased
Diet:- mixed
Sleep :- not adequate due pain of lower back
Bowel and bladder movements:- regular
No drug allergies present
No history of alcohol consumption, tobacco smoking and chewing.
General examination:-
Patient is in unconscious state and connected to mechanical ventilator.
thin built, poorly nourished
Pallor:- absent
Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Generalized lymphadenopathy:- absent
Bilateral pedal edema :- present
O/E :
Temp:- 106 F
PR- 134 bpm
BP- 80/60 mm of Hg
Spo2-75% at room air
RR : 36cpm
GRBS- 116 mg%
On abdominal examination:
Inspection:
Shape of abdomen is scaphoid
Flanks are free
Umblicus is in position, inverted
Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.
No visible veins.
No engorged veins.
Movements of abdominal wall are normal, no visible gaatric peristalsis
Palpation:
Liver examination:
On superficial palpation
no tenderness , raised temperature
On deep palpation
No tenderness in liver
Non pulsatile
Spleen examination:
No tenderness and pain
Percussion :
No ascitic fluid present.
Percussion of Liver for Liver Span :
Auscultation
Normal bowel sounds heard.
2. Bruit - renal artery bruit heard.
iliac artery bruit heard.
Respiratory system examination :
Inspection :
Position of trachea central
Slight dropping of right shoulder
No intercostal indrawing
No supraclavicular hallowness
Shape and symmetry of the chest not normal.
No dilated veins.
No visible scars.
accessory muscles of respiration not prominent.
Palpation :
On three finger test : position of the trachea central.
Respiratory movements are
Measurement of left and right hemithorax :
Antero posterior diameter :
Transverse diameter at the level of nipples :
AP/transverse diameter ratio =
Distance between vertebrae and infrascapular angle on right and left side is same =
Percussion :
On direct percussion in clavicular area
On right side :
On left side :
Tidal percussion:
Traubes space percussion :
Ascultation :
Vocal resonence :
Right left
vesicular breath sounds heard connected to ventilation tube.
Bilateral air entry positive.
crackles heard.
CVS Examination :
Inspection :
No abnormal palsations
No visible scars.
chest deformity on the right side of the chest.
Mediastinum normal
Trachea central in position.
Palpation :
Mediastinal position : apex beat
Position of trachea central.
Percussion :
Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.
CNS :
INVESTIGATIONS
Complete blood picture
Liver function test
Renal function test
Blood grouping
ECG
Chest x ray
Complete urine examination
HIV
HBsAg
Died due to cardiac arrest on 19/04/23 at 4:30 am in the morning.
