18 YEAR OLD GIRL WITH LOSS OF APPETITE, DYSPNEA,FEVER,COUGH,PEDALEDEMA AND FACIAL PUFFINESS

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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.

CHIEF COMPLAINTS:

An 18 year old female patient who is apparently asymptomatic 2 yrs ago then have a history of irregular menstrual cycle

then developed loss of appetite ,dyspnea,fever,facial puffiness,bilateral pedal edema since 20 days 

cough since 10 days

HISTORY OF PRESENTING ILLNESS:

patient daily routine when she is apparently assymptomatic 

"she wakes up at 7 am and completes her routine things and do brush and  drink some tea and eats rice for breakfast at 10 am and then she watches tv and at 2 pm(rice) she have her lunch and then afternoon she takes a nap and evening she may or may not have some snacks which is mostly some junk food rarely some fruits and then spends some time with her sisters and have her dinner (rice) ,sleeps at 10pm"

patient was apparently assymptomatic until her mother notices that she didnt attain her menarche even after 14 years of age after which she attained her menarche at the age of 15 yrs 

she born out of non consanguinous marriage of normal delivery at home.she was fed by milk upto 1 year and she attained all her milestones on time and is fully immunized.

she is the eldest  and she has 2 younger siblings, one currently in her 7th grade and the youngest in her 4th grade. she studied till 12th grade and planning to join in degree college.

she  complains of irregular menstrual cycles since the past 2 years  she gets her cycle every 4 months and it lasts for 5 days ,she complains of increased flow during these 5 days ,she changes around 5 pads per day 

Dyspnea since 20 days which is insidious in onset and gradually progressive from grade 2 to 3 MMRC

Loss of appetite since 20 days she complained that while having food she is having nausea so she refused to eat food

Fever since 20 days which was low graded on and off type and was reduced after taking medication

Facial puffiness and bilateral pedal edema since 20 days 

Cough since 10 days which was non productive in nature and was not blood stained no diurinal variation

HER DAILY ROUTINE FROM 20 DAYS

"she wakes and completes her routine activities and eats breakfast at 10 am and may or may not eat lunch and eats a little for dinner and no other fruits or supplementary foods are taken"

"from 2 days she is eating idli as breakfast and having some rice for lunch at 2pm and having some fruits at 5pm and having dinner (rice) at 7pm"

PAST HISTORY:

No similar complaints in the past

No history of DM,HTN,TB,Epilepsy

PERSONAL HISTORY:

Appetite:loss of appetite

diet: vegetables and egg but she dont eat meat

bowel and bladder:regular

addictions: none

FAMILY HISTORY:

Her mother didnt conceive for 3 years after marriage due to some gynic problem

GENERAL EXAMINATION:

Patient is conscious ,coherent,cooperative well oriented to time, place and person

patient is thin built and malnourished

pallor present,biateral pedal edema present

no icterus,no cyanosis,no clubbing,no koilonychia,no lymaphadanopathy

raised jvp

vitals:

bp: 110/50 mmof hg

rr: 18 cc/min

pulse rate:110 beats /min

temperature:98f

SYSTEMIC EXAMINATION:

CVS:

s1 and s2 heard

parasternal heave is present 

raised jvp

RESPIRATORY SYSTEM:

INSPECTION:

shape of chest: bilaterally symmetrical

no scars and sinuses on chest 

no drooping shoulder

PALPATION:

inspectory findings confirmed

Apex beat felt at 5th intercoastal space medial to midclavicular line and diffuse type

PERCUSSION:

all the areas are resonant

AUSCULTATION:

normal vesicular breath sounds are heard

ABDOMEN:

INSPECTION:

shape of abdomen-scaphoid

umbilicus-inverted

no sinuses or scars on abdomen

PALPATION:

No rise in temperature

no tenderness on palpation

no palpable mass

no free fluid

liver  not palpable 

spleen not palpable

PERCUSSION:

no fluid thrill

no shifting dullness

AUSCULTATION:

Bowel sounds heard

CNS:

conscious

speech normal

no neck stiffness

kernigs sign not seen

sensory system : intact

motor system:

reflexes normal

power of lowerlimb and upper limb 5/5

INVESTIGATIONS:

ELECTROLYTES:

NA+-13.6

K+-3.5

CL-105

Serum creatinine-0.4

Uric acid-1.5

Urea-13

LFT:

Total bilirubin - 0.74

Direct bilirubin -0.20

AST - 25

ALT -10

ALP(alkaline phosphatse) -163

Total protein-6.5

Albumin-3.5

Albumin/globulin-1.20

HEMOGRAM:

HB: 1.7

Total leucocyte -1600

PCV -6.7

MCV -76.1

MCH -19.3

MCHC-25.4

RDW -29.1

RBC-88000

PLT-45000

PERIPHERAL SMEAR-microcytic hypochromic picture with tear drop cells,pencilforms,Anisopoikilocytosis

CUE:

pus cells - 2.3

epithelial cells -2.3

albumin -nil

sugar-nil

bilesalt-nil

bilepigment- nil

specific gravity-1.010

blood group-o+ve

APTT - 33 SEC

PT - 17 SEC

BT - 2 MIN

CT -5 MIN

CXR:

ECG:

FEVER CHART:

2d echo

USG

PROVISIONAL DIAGNOSIS:

pancytopenia

TREATMENT:

DOLO 650 MG

INJ OPTINEURON 1 AMP IN 100 ML NS/IV/OD

INJ MONOCEF 1GM IV/BD

ONE UNIT OF BLOOD TRANSFUSION DONE ON 23/02/2022