36 y/o woman with massive pericardial effusion
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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.
Patient came to the OPD with chief complaints of generalised swelling of body since 3 to 4 months, shortness of breath since 4 months.
History of presenting illness : Pt was apparently alright 4 months back then she developed swelling of both lower limbs gradually progressive extending upto knee - pitting type. Gradually swelling developed on both upper limbs and also leading to facial puffiness and abdominal distension.
C/o shortness of breath since 4 months initially grade 2 now progressed to grade 3 relieved by taking rest and aggravated on walking/ excessive talking. Orthopnea +, no pnd
C/o abdominal distension since 4 months gradually progressive
C/o decreased urine output since 4 months
Sob is associated with left sided chest pain
No c/o giddiness, sweating, palpitations
No c/o fever, nausea, vomitings, pain abdomen, burning micturition
Past history : k/c/o DM since 12 yrs (developed it during her 5th month of pregnancy)now using INJ H.Mixtard 10U OD (night) and T.Glimi 2mg+T.Metformin 5mg OD
H/o PTB 20yrs back - used ATT for 6 months and stopped
Not a k/c/o HTN, CVA, CAD, epilepsy, thyroid disorders and bronchial asthma
Ulcer over left foot since 2 weeks
H/o blood transfusion 1.5 yrs back, no reaction
Surgical history - h/o lt lung lobectomy 1.5 yrs back
Personal history : she is a housewife
Appetite - decreased since 4 months
Diet - mixed
Sleep- inadequate
Bowel - constipation + since 4 months
Bladder - decreased output since 4 months
No addictions
Family history : no significant family history
Menstrual history : irregular menstrual cycles since 5 to 6 months; amenorrhea since 5 months
Vitals :
Temp - afebrile
BP - 130/80 mm hg
PR - 84 bpm
RR - 22 cpm
sPO2 - 90 % at RA
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