60 year female with left diaphragmatic palsy with eventration
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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 diagnosis and treatment plan .
60 year old female came with chief complaints of breathlessness since 3 days, pedal edema since 1 month.
Patient was apparently asymptomatic 20 years back , then she developed DM, hypothyroidism and was on regular medication since then.Pt has H/O SOB on and off since 6 months which was initially of grade 2 then progressed to grade 4 since then for which she visited cardiologist in our hospital and is on Aspirin , Atorvas, Clopidogrel since then .Patient developed pedal edema pitting type since 1 month which gradually progressed to anasarca.
She developed severe episode of sob for which she visited a local doctor and managed conservatively.
On Jan 15th , patient had 1 episode of sudden loss of consciousness and was taken to a local hospital and from there she was referred to another hospital.On the way to the hospital, pt had an episode of involuntary micturition and sob and LOC( regained consciousness after 1 hr)associated with involuntary movements for which she was admitted and discharged after 3 days.
Since yesterday morning patient developed SOB admitted in a local hospital and suffered a cardiac arrest( and revived after 10 mins)and referred to our hospital.
Patient now complains of pain abdomen since 1 day and patient hasn’t passed stools since 5 days.
PAST HISTORY:
k/c/o DM , hypothyroidism.
Not a k/c/o HTN , epilepsy, asthma , CAD , CVD,TB
Hysterectomy 20 years ago.
PERSONAL HISTORY:
Appetite-Decreased
Diet - Mixed
Bowel - Regular
Bladder - constipation since 5 days
Sleep - Decreased.
General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Pedal edema - pitting type extending till knee
VITALS : Temp - 98.6 F
PR - 86 bpm
BP - 120/70 mmhg
RR - 30 cpm
SPO2 - 76% onRA
GRBS - 102 mg/dl
Systemic examination:
RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion:
Resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.
Palpitation:
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves
Auscultation :
S1 and S2 heard.
PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration
No scars , sinuses , engorged veins, visible pulsations .
Hernial orifices are free.
Palpitation :
Abdomen is soft and non tender .
No organomegaly.
Percussion :
Tympanic note heard over the abdomen.
Auscultation:
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM:on the day of presentation
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Ulcer over the left lower limb:
CXR :
CT CHEST:
INVESTIGATIONS:
On 24/1:
Treatment:
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