A 47 yr old female
Gm e-log
July 07, 2022
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form
I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings
investigations and come with a diagnosis and treatment plan.
A 47 yr old female housewife by occupation came to OPD with chief complaints of pedal oedma abdominal distension and shortness of breath since 2months.
History of present illness:
She was apparently asymptomatic 6yrs back and had generalised Body Weakness for which she came to the hospital and was diagnosed with DM-2 and was on regular medication. 2 months Back pt had pedal edema B/L below Hip Pitting type and abdominal distension for which she visited nearby hospital and was diagnosed with hypertension and hypothyroidism after necessary tests , pedal edema was subsided with medication but abdominal distension was not subsided for which She Came to our Hospital,admitted and treated for 1 week for low SAAG low Protein Ascites secondary to Koch's diabetic nephropathy. FNAC was done and S/o of chronic granulomatous lymphadenitis.Now pt came for excisional biospy.
History of past illness:
K/c/o of DM : 6yrs on medication
K/c/o of hypertension:2months back
K/c/o of hypothyroidism:2months back
Treatment History:
For diabetes on HAI 4U S/C TID
For hypertension Telmi 40mg OD
Personal History:
Diet : mixed
Appetite: Decreased
Bowel movement: regular
Micturition: Normal
Addictions: Nil
No allergic History
Family history:
No relavent family history
General Examination:
Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built
There are no signs of
Cyanosis
Pallor
Clubbing
Icterus
There is presence of
Lymphadenopathy
Oedema present: B/L Pitting Type and anasarca
Palpable lymph node is present in the posterior triangle of neck
VITALS:
Temperature: 98.6 degree Fahrenheit
Pulse rate: 76 per min
Respiratory rate: 16 per min
BP: 110/70
SpO2: 96%
Systemic Examination:
CARDIOVASCULAR SYSTEM
slightly elevated jvp
S1 S2 +
RESPIRATORY SYSTEM
Dyspnoea : yes
Wheeze : no
Postion of trachea: central
Breath sounds:
ABDOMEN
Distended
Tenderness present
Free fluid present
Liver and spleen is not palpable
Bowel sounds are normal
CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15
Investigations:
C-Reactive protein
Random blood sugar
Diagnosis:
Low SAAG low Ascites secondary to diabetic nephropathy
Right lymphadenopathy - chronic granulomatous lymadenitis.
TREATMENT:
Inj LASIX 20 mg BD
Tab TELMA 40 mg OD
Tab ULTRACET 1/2 QID
Tab OROFER OD
Inj HAI SC tid before meals
5/7/22
No fever
Same treatment given
6/7/22
No fever
C-Reactive protein
Random blood sugar
DIAGNOSIS:
Low SAAG low Ascites secondary to diabetic nephropathy
Right lymphadenopathy - chronic granulomatous lymadenitis.
TREATMENT:
Inj LASIX 20 mg BD
Tab TELMA 40 mg OD
Tab ULTRACET 1/2 QID
Tab OROFER OD
Inj HAI SC tid before meals
5/7/22
No fever
Same treatment given
6/7/22
No fever
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