47 Year old female patient with Ascitis and Extra pulmonary tuberculous
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I have 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.
A 47 year old patient,House wife by Occupation,Resident of Nalgonda,Came to OPD with cheif complaints of
Generalized itching since 1 month.
Difficulty in breathing since 7 days.
Back pain since 7 days.
HOPI:
Patient was apparently asymptomatic 6 years back then she developed giddiness for which she went to Hospital and diagnosed as diabetes and she was on regular medication.
In March 2022 there is a history of edema in both lower limbs up to thighs ? for which she went to hospital in Nalgonda and was discharged after resolving edema? also in her tests she was found to be having Hypothyroidism and Hypertension and she was started on regular medication.
In April 2022 she was having Abdominal Distension,She diagnosed as Ascitics for which ascitic tap was done .At that time on further examination she was found to be have cervival lymphadenopathy.
In June,FNAC was done? and found to be have extra pulmonary tuberculosis.
She is on ATT from 21 july.
H/o generalized itching since 1 month?
H/o Shortness of breath since 1 week which is insidious in onset Grade 4,Not associated with orthopnea,PND,chest pain.?
H/o Back pain which is continuous,non radiating.
PAST HISTORY:
She is known case of diabetes since 6 year Hypertension hypothyroidism since 5 month. and tuberculosi?s.
No H/o epilepsy ,CAD.
PERSONAL HISTORY:
Diet - Mixed
Appetite -Normal
Bowel and bladder -Regular.
Sleep - adequate.
Addiction :No
FAMILY HISTORY:
Mother is known case of Diabetic.
Clinical Pictures:
General Examination:
Patient is conscious ,coherent ,cooperative
She is moderately built and nourished.
Pallor - present
Icterus - Absent
Cyanosis - Absent
Clubbing - present
lymphadenopathy - absent
Pedal edema -present(bilateral pedal edema pitting type).
Vitals : on the day of admission
Temperature - Afebrile
Pulse rate - 97 bpm
Respiratory rate - 19 cpm
BP- 130/70 mmHg.
GRBS - 445mg/dl
Systemic Examination:
CVS: S1,S2+ heard
R/S: BAE present and Clear;
P/A : Soft, non tender,Distended,Shifting dullness present and fluid thrill absent.
CNS: intact.
INVESTIGATIONS:
USG:
