อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303)
นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Fever case 1............................................................................4 Fever case 2............................................................................6 Weight gain..............................................................................8 Weight loss..............................................................................10
PART 2
Fever
case 1 : Mr. Prakorn
The patient is a 15-year-old student who has an abrupt onset of fever for 2 days. Most of the temperature readings are between 38.4-39.2oC. He has no previous illness and complains only of fever, mild headache, malaise, fatigue, and anorexia. There is no chill, cough, sore throat,expectoration, nausea, vomiting, abdominal pain, diarrhea, or joint pain. He takes paracetamol for fever every 6 hours. Antipyretic effect lasts only for a few hours. He denies history of traveling out of town in the last 3 months and has no pets. He also denies smoking, alcohol drinking, or intravenous drug abuse. One of his class-mate had a febrile illness last week and was admitted for 3 days in another hospital. He stays in his parents’ house in Lad-Krabang and studies in a high school nearby. He also reports the big pond in the school. Physical examinations Vital signs T 39.0oC, PR 100/min regular, RR 20/min, BP 110/70 mmHg General A young boy, febrile, looks weak, appearance not pale, no jaundice HEENT Eyes: no conjunctival injection, normal fundi Ears: no discharge, intact eardrum Oral cavity: normal, no white patches, no injection of tonsils or pharynx LN: no lymphadenopathy Thyroid: not enlarged
4 | Symptomatology part 2
PART 2 Physical examinations CVS Jugular venous pressure: not raised Apex at 5th ICS at midclavicular line No parasternal lift, normal S1, S2, and no murmur RS Normal chest movement, equal bilaterally Normal percussion and breath sounds No adventitious breath sounds Abdomen Not distended, not tender Liver span 13 cm by percussion, mild tenderness, and just palpable at lower right costal margin Spleen: not palpable and no dullness on percussion Bowel sounds: normal
Question 1. What is the main problem of this patient? 2. Analyze the information from history and physical examination, and give your differential diagnosis.
Symptomatology part 2 | 5
PART 2
Fever
case 2 : Ms. Somjai
The patient is a 20-year-old college student who has a gradual onset of fever for 2 weeks. Most of the temperature readings are between 37.8-38.5oC. She has no previous illness and complains only of fever, fatigue, joint pain and rashes on her face. There is no chill, cough, sore throat, expectoration, nausea, vomiting, abdominal pain, diarrhea, dysuria or weight loss. She reports that the fever has been the same for the past 2 weeks. The rashes on her face occurred last week and slightly progress. She denies history of traveling out of town in the last 3 months and has no pets. She also denies smoking, alcohol drinking, or intravenous drug abuse. She has no history of contact to tuberculosis. She lives in her college dormitory and studies in a college in Bangkok. She accepts the sexual relationship with her boyfriend for the past 3 months. Physical examinations Vital signs T 38.0oC, PR 90/min regular, RR 18/min, BP 120/70 mmHg General A young woman, alert, febrile, mildly pale, no appearance jaundice HEENT Eyes: no conjunctival injection, normal fundi Ears: no discharge, intact eardrum Face: erythematous rashes on forehead, and both cheeks
6 | Symptomatology part 2
PART 2 Physical examinations Oral cavity: normal, no white patches, no injection of tonsils or pharynx LN: no lymphadenopathy Thyroid: not enlarged CVS Jugular venous pressure: not raised Apex at 5th ICS at midclavicular line No parasternal lift, normal S1, S2, and no murmur RS Normal chest movement, equal bilaterally Normal percussion and breath sounds No adventitious breath sounds Abdomen Not distended, not tender Liver span 11 cm by percussion, and not palpable Spleen: not palpable and no dullness on percussion Bowel sounds: normal
Question 1. What is the main problem of this patient? 2. Analyze the information from history and physical examination, and give your differential diagnosis.
Symptomatology part 2 | 7
PART 2
Weight gain A 40-year-old woman presents with weight gain 20 kg over 6 months. The weight gain is noted to be prominent on her central trunk and neck. Facial rounding and fullness as well as violaceous striae on the axillae, abdomen and upper thigh are reported. She feels tired and has difficulty climbing stairs or getting out of a chair. She complains of irregular periods and waxes her skin twice a month because of hair growth on her upper lip, arms and legs. She has increased appetite without change in activity level. She is a non-smoker and occasionally drinks alcohol. She had a past history of frequent attacks of pain and swelling in her fingers, wrists, elbows and knees occurring over 2 years and associated with a positive rheumatoid factor in serum. The rheumatoid arthritis was diagnosed. Many analgesics were used. These symptoms were slightly improved. She lost follow up from her primary doctor. In the last year, she had begun to take hand rolled pills (ยาลูกกลอน) and traditional Chinese medicines on the advice of her friend. Physical examination: The vital signs are T 37.3oC, PR 80/min and regular, RR 20/min, BP 140/90 mmHg. Her weight and height are 90 kg and 157 cm, respectively. There are dorsocervical and supraclavicular fat pad. Mild facial plethora and fullness are evident. Her skin is thin and easy bruising. Thyroid gland is not prominent. Cardiovascular and respiratory system are not remarkable. Proximal muscle weakness was noted.
8 | Symptomatology part 2
PART 2 Questions 1. List the problem of this patient? 2. What is the most likely diagnosis?
Symptomatology part 2 | 9
PART 2
Weight loss A 36-year-old woman visits her physician because of severe nervousness and weight loss for the past 3 months. She has always considered herself to be a nervous person, but since the death of her mother she has been more so, cries easily, is jumpy and fidgety, and her hands tremble. She feels warm all the time, dresses lightly even though it is winter, and argues frequently with her husband who wants the windows shut. Her appetite has remained good; she consumes more than her usual fare, yet claims to have lost 15 lb in 3 months according to her bathroom scale. She notes frequent palpitations and her legs and thighs fatigue easily, especially on walking up steps. Her menses had become scant and stopped completely 2 months ago. There is no cough, dyspnea, orthopnea, nocturia, frequent urination, or unusual thirst. She has had two to three formed bowel movements daily over the past few months, but the stools are not foul or greasy and do not float. She does not drink alcohol, consumes five cups of coffee, and smokes five to ten cigarettes each day. Her clothes have become too large and she needs another wardrobe; this depresses her and gives her more anxiety. Though her mother died of a heart condition, she had some kind of thyroid disease for many years.
10 | Symptomatology part 2
PART 2 Examination discloses a lean nervous woman in no distress. Her skin is thin, velvety, warm, and moist; this is especially noticeable on handshake. A fine rapid tremor is noted on the outstretched hands. The vital signs are: T 37.5oC, PR 120 and irregular, RR 20, BP 160/70. Her eyeballs are prominent and sclera is noted between the upper lid and cornea. Lid lag is present when she lowers her eyes, and she has infrequent blinking and inability to converge her eyes on a near object. Her hair is fine, silky, and scant. The thyroid gland is diffusely though only moderately enlarged, and no nodules are palpated. A systolic bruit is heard over each lower pole of the thyroid gland and a venous hum is heard in both supraclavicular areas. The heart rate is 138 and is grossly irregular, and a third heart sound is discernible at the apex. The apex beat is forceful, the left ventricular impulse is strong, and the lower portion of the neck is felt to pulsate with each heartbeat.
Questions 1. List the problem of this patient? 2. What is the most likely diagnosis?
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