Name: K.Sannith Reddy
Roll no. 65
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.
Cheif complaints:
patient came to the General medicine Opd with clo Cough (dry) & SOB 2months ago
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic till 2months ago. Then she had Dry Cough with SOB for 2 days she went to RMP doctor and she was treated with medication ( unknown) then symptoms subsided
she is farmer by occupation 2 months age while she is carrying Dry grass she had sudden onset of cough and sob started in the evening and present for two days; went to Rmp doctor and managed with medications (unknown) .
Cough is dry; Intermmitent not associated
with chest pain while coughing.
Not associated with Fever,Headache.
SOB (G-II) on lifting weights. Relieves after taking medications( unknown)
not alw orthopnea, & PND, Palpitations,chest pain
HISTORY OF PAST ILLNESS
N/Klc/o HTN/DM/CAD/ Epilepsy/ TB /CVA
PERSONAL HISTORY
DIET MIXED
SLEEP ADEQUATE
BOWEL AND BLADDER MOVEMENTS REGULAR
ALCOHOL OCCASIONAL
NO SIGNIFICANT FAMILY HISTORY.
GENERAL EXAMINATION :
PT IS C/C/C WELL ORIENTED TO TIME ,PLACE AND PERSON
vitals @ admission :
BP: 150/90mm hg
PR: 80BPM,REGULAR
GRBS: 447MG/DL
TEMP AFEBRILE
NO PALOR,ICTERUS,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY
SYSTEMIC EXAMINATION:
RS: BAE+ , NVBS HEARD ,
CREPTS ABSENT, NO WHEEZE,NO RHONCHI
CVS S1,S2 HEARD ,NO MURMURS
P/A SOFT ,NT
CNS: NFND
INVESTIGATIONS:
GRBS
At the time of admission : 447mg/dl
22/12/22
8 am 122mg/dl
10am 104mg/dl (6units HAI +6unitsNPH given)
10pm 205mg/dl
23/12/22
2am -160mg/dl
8 am 134mg/dl
Hemogram:
HB: 12:4
PCV: 36.1
TC: 7200
NEU: 54
MCV: 86.6
MCH: 29.7
LYM: 36
MCHC-34.3
MON: 07
RDW-CV. 11.4
EOS: 03
RBC: 4.17
PLT 2.38 lakh
CUE :
ALBUMIN TRACE
SUGARS NIL
PUS CELLS 2-3
Urine for ketones neagtive
Fbs- 100mg/dl
Plbs- 152mg/dl
HbA1c 6.8
Chest xray:
ECG:
2d echo:
mitral valve : pml calcification, restricted.
RVSP:35MM HG , Ef 67%,IVC 0.9cm
+ Mild AR+/MR+,Trivial TR+
NO RWMA ,no AS/MS ,sclerotic Av
Good LV systolic function
Diastolic dysfunction+ NO PAH/PE
Provisional diagnosis:
1)? Acute exacerbation of asthma
2)? Allergic bronchitis
Treatment given : on 22/12/22
1) TAB MONTEK LC PO BD (1-X-1)
2) SYP GRYLLINCTUS 15ML PO BD
3) TAB DOLO 650 MG PO SOS
4)6units HAI + 6 UNITS NPH
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