45yr FEMALE WITH FEVER, VOMITINGS AND SHORTNESS OF BREATH
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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 treatment plan.
A 45year female Presented with
C/O Fever since 5 days
C/O Vomitings since 4 days
C/O Headache since 4 days
C/O Shortness of breath since 2 days
Patient was apparently asymptomatic 5 days back then he developed fever (Sudden in onset gradually progressive ) not associated with chills and rigor, no diurnal variations, no Sweating.
C/O Vomitings Since 4 days (non bilious), non- projectile,food particles as content
C/O shortness of breadth (grade 3) according to NYHA classification, no orthopnea, no PND, no Palpitations.
C/O B/ L Pedal edema (Since Yesterday) Pithing type, not associated with decreased Urine output.
K/C/O HTN Since 4 Months (unknown Medication)
C/O loss of appetite
C/O On and off fever Since One month (low grade).
No H/O weight loss
Not a k/C/O DM/ TB / epilepsy / Thyroid.
Personal History.:
Married
Occupation:
Appetite: DECREASED
Diet: Mixed
B&B : Regular
No Addictions
Menstrual History:
Age of Menarche :
cycles:
Family History:
On General Physical Examination:
pt is C / C / C, .
Pedal Edema - Present - B/L
JVP: Raised .
Cervical lymph nodes - enlarged
Scary look of eyes
No signs of pallor, icterus, cyanosis, clubbing .
Vitals:
Afebrile
PR: 100 bpm
RR: 16 Cpm
BP: 110 / 70 mm Hg
SPO2: 99% at RA
CVS: S1, S2+
RS: BAE +, Rt sided expiratory crepts + at SMA & IMA.
P/A: Soft , NT, BS +
CNS: NAD.
Investigations:
30 / 09 / 21: X-ray chest PA and Lateral view: Right upper lobar Pneumonia with consolidation in posterior basal Segment above the oblique fissure.
On 01 / 10 / 21:
2d ECHO: EF: 58%, Mild MR+ / AR +, Mild to moderate TR+ with PAH, NO RWMA, No AS/MS, Sclerotic AV, Good LV systolic function, Diastolic dysfunction +, NO PE.
USG Neck :
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