อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303) นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Dysuria case 1.........................................................................4 Hematuria................................................................................6 Edema case 1..........................................................................8 Edema case 2..........................................................................10
PART 2
Dysuria
case 1
History The patient is a 25-year-old woman who has recently been married for one month. Just yesterday, she started experiencing burning sensation during and especially at the end of urination. There was an increase in frequency of urination while, each time, the amount of urine is less than usual. After she finished urination, there was an urge to urinate again. She noticed that the urine has become cloudy. Occasionally, there was small amount of blood in the urine. She also felt mild pain at the suprapubic area. She admitted to feeling mild generalized body ache and nausea. She did not notice any fever or back pain. She denied passing any stone. Her bowel movement has been normal. She admitted to occasionally holding urine for prolonged period in the past. She just started having regular sexual intercourse after the marriage but denied any injury related to the intercourse. There was no abnormal vaginal discharge or bleeding. Her period has been regular. Her partner denied any similar symptoms.
4 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 36.8°C, PR 96/min regular, RR 18/min, BP 110/80 mmHg General A pleasant young woman who is not in apparent appearance distress HEENT Pharynx and tonsils are not injected Thyroid gland is not enlarged There is no lymphadenopathy Lungs Trachea is in midline Symmetrical chest movement with equal breath sounds bilaterally Both lungs are clear on auscultation CVS No engorged neck vein PMI is at 5th intercostals space, midclavicular line No heaving or thrill S1 and S2 are normal without audible murmur Abdomen Normal bowel sound Soft with mild tenderness at suprapubic area No rebound tenderness Liver and spleen are not palpable Both CVAs are not tender Extremities No rash or edema
Questions 1. What is the main problem of this patient? 2. Analyze the information from history and physical examination, what is/are the precipitating cause of this patient’s problem?
Symptomatology part 2 | 5
PART 2
Hematuria ชายอายุ 40 ปี บ้านอยู่อุบลราชธานี อาชีพค้าชาย อาการสำ�คัญ: มีอาการปัสสาวะสีแดงมา 2-3 เดือน ประวัติปัจจุบัน: ปัสสาวะช่วงแรกมีสีแดงตลอดการถ่ายปัสสาวะ บางครั้งตั้งทิ้งไว้แล้ว จะเปลี่ยนเป็นสีคล้ำ� ๆ หรือมีตะกอนสีแดง ๆ บางครั้งมีลิ่มเลือดออกมาด้วย ไม่เคยมีเม็ดกรวด เม็ดทรายออกมากับปัสสาวะไม่มีอาการแสบขัด เจ็บหรือ ต้องเบ่งเวลาปัสสาวะ ปัสสาวะวันละประมาณ 2 ขวดลิตร กลางวันประมาณ 3 ครั้ง เย็น 2 ครั้ง เข้านอนแล้วต้องลุกมาปัสสาวะ 2-3 ครั้งทุกคืน กลั้น ปัสสาวะได้ดี ไม่เคยมีไข้ ปวดข้อ หรือมีผื่นขึ้นตามตัว ไม่เคยมีเลือดออกง่าย หรือจ้ำ�เลือดตามตัวมาก่อน ซื้อยาแก้ปวดกินประจำ�
6 | Symptomatology part 2
PART 2 Physical examinations Vital signs T 37oC, HR 72/min, RR 20/min, BP 150/100 mmHg, BW 65 kg, hight 160 cm. General Thai male, looks anxious, good cooperation, mild appearance pallor, no edema, no bruise HEENT Normal Heart Normal Lungs Clear Abdomen Palpable masses at paraumbilical area both sides, size ~20 cm, smooth, firm consistency, not tender, bimanual papations - positive CVA Not tender Extremities No pitting edema Neurological no abnormal findings exam
Questions
1. What is the main problem of this patient?
2. Analyze the information from history and physical examination, and give differential and the most likely diagnosis.
3. What should you advice to the patient?
Symptomatology part 2 | 7
PART 2
Edema
case 1
History The patient is a 4 years old boy who presents with increased swelling of both legs for 2 weeks. His weight has increased 3 kilograms. His mother notes that his urine has been frothy with slight decrease in urine volume. He has no dysuria or hematuria. He has not noted any swellings of his abdomen, and has not had any chest pain, shortness of breath either on exertion, or lying flat. He does not have a rash or joint pain or oral ulcers or recent sore throat. He has had no previous illness. He has not had cardiac, liver, or kidney problems previously. He grows well and has had development appropriate to his age. He denies taking any medications in the last month including non-steroidal anti-inflammatory agents and antibiotics. His father has hypertension, but no one in the family has heart, kidney or liver diseases. He is in the kindergarten. He lives with his parents in Bangkok. Physical examination Vital signs T 37.0oC, PR 85 min, RR 20/min, BP 95/50 mmHg, weight 20 kg, height 100 cm. General A young boy, not in acute distress, not pale, appearance no jaundice, no spider nevi, no rash, no joint swellings, no tremor, no goiter HEENT Eyes: not injected, normal fundi Ears: normal Oral cavity: normal, no ulcers Thyroid gland: not enlarged
8 | Symptomatology part 2
PART 2 Physical examination CVS Jugular venous pulse (JVP): not raised Apex at 5th ICS, just medial to left midclavicular line. No parasternal lift, no thrusting apex Normal S1, S2, no extra sounds RS Normal chest movement, equal bilaterally Normal percussion Normal breath sounds, no adventitious sounds Abdomen Not distended, not tender Liver span-normal, spleen-not palpable No ascites Extremities Moderate bilateral pitting edema (up to his knees), not inflamed or tender, no venous dilatation. Lymph nodes in groin are normal
Question 1. What is the main problem of this patient?
2. Analyze the information from the history and the physical examination, and give your differential diagnosis
Symptomatology part 2 | 9
PART 2
Edema
case 2
A 10-year-old girl presents with bilateral puffy eyelids and pretibial edema for 3 days, and dyspnea for 1 day. History The patient is a 10 years old girl who presents with puffy eyelids and pretibial edema for 3 days. Her weight has increased 2 kilograms. She notes that her urine volume has decreased for 3 days and today urine color becomes red brown. This morning she complains of headache. She has shortness of breath and dyspnea on excretion especially during walking upstairs. She does not have a rash or joint pain or oral ulcer. However she had history of severe sore throat requiring antibiotic treatment 14 days ago. She has no cardiac, liver or kidney problem previously. She grows well. She denies taking any medication except antibiotic for the sore throat. Her family denies heart, kidney, liver disease and hypertension. She lives with her parents in Bangkok. Physical examination Vital signs T 37.0oC, PR 100 min, RR 24/min, BP 140/90 mmHg, weight 30 kg, height 135 cm. General A Thai girl, not pale, no jaundice, no spider nevi, appearance no rash, no joint swellings,no tremor, no goiter HEENT Eyes: not injected, normal fundi Ears: normal Oral cavity: normal, no ulcers Thyroid gland: not enlarged
10 | Symptomatology part 2
PART 2 Physical examination CVS Jugular venous pulse (JVP): raised 5 cm above clavicle Apex at 5th ICS, just lateral to left midclavicular line. No parasternal lift, no thrusting apex Normal S1, S2, no extra sounds, no murmur RS Normal chest movement, equal bilaterally Normal percussion Normal breath sounds, no adventitious sounds Abdomen Not distended, not tender Liver 2 cm. below right costal margin, span 10 cm. No ascites Extremities Non pitting edema at both pretibial area, not inflamed or tender, no venous dilatation. Lymph nodes in groin are normal.
Question 1. What is the main problem of this patient?
2. Analyze the information from the history and the physical examination, and give your differential diagnosis
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