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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
14 March 2023
13 Y/F came to OPD with chief complaints of
* Shortness of breath since yesterday
* 4 episodes of vomitings (since 10 am , yesterday)
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic till the age of 11years when she noticed bilateral multiple neck swellings ,non mobile associated with pain.
She was taken to local hospital with complaints of neck swellings,fever and cough (on and off)
They initiated her on ATT( Anti tubercular drugs) as her mother has also has kochs
She used ATT for 2months started in 2021 june
After initiating ATT, fever did not subside, so they stopped ATT and was referred to Hyderabad.
Patient was taken to X hospital where she was evaluated for kochs but none of the investigations showed Acid fast bacilli.
At the same time she also had complaints of knee pains and wrist joint pains
In view of joint pains she was referred to Y hospital
In Y hospital they suspected it to be AUTOIMMUNE
And started her on
Tab Wysolone
Tab Hydroxychloroquine
which she used for 15 days and stopped ( symptoms subsides) and later did not go there for follow up
(ANA ELISA-equivocal,
ANA IFA-negative,
Anti Ds DNA ELISA-Positive,
Anti Ds DNA IFA negative)
She was taken to another local hospital with c/o joint pains,facial puffiness,pedal edema,fever ,cough
Lymph node biopsy was done in May 2022 ?reactive(no report available but attendor was informed that it was negative for kochs)
So Mycobacterial gene expert test was done on blood sample which was also negative
But she was initiated on ATT empirically on may/2022.
In June 2022 she started developing pigmentation/rash over face which then was seen on scalp evident because of hair loss and on trunk since 3 months,not associated with itching.
And also pedal edema upto ankles which then progressed till knee in the last 3 months(pitting type)
Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis.
Lymph node biopsy was done
Mycobacterial gene expert test was done
No reports available
So they started her on ATT and recieved regular treatment for 6m.
Her symptoms settled and she was fine until January 10 when she develop edema again (generalized)
They went to another hospital and got tested and was told to have proteinuria.
In January and February she had mild fever and 1 week back she developed fever and edema again.
On 13 March
From 10 am in the morning
Patient had 4 episodes of vomitings, after 2 hrs of food intake , non bilious and non blood stained, food particles and water as content.
She also complains of nausea
Patient later on the same day developed shortness of breath of Grade 3 ( NYHA)
PAST HISTORY
K/C/o e
Extra pulmonary tuberculosis (1year back used att for 6 months)
N/k/c/o hypertension, Diabetes mellitus, epilepsy, asthma, coronary artery disease, cardiovascular disease.
TREATMENT HISTORY
Used ATT for 6 months for TB
Birth and Family history
1st child
2nd degree consanguineous marriage
Born in 2010
LSCS
Father has no idea about immunisation status
Mother-has 2 children
The current pt is the elder one(birth in 2010)
2nd child born in 2013
In 2014 mother diagnosed with kochs - expired in 2022 sept(did not use ATT regularly)
PERSONAL HISTORY
Single
Occupation:student
Diet - Mixed
Appetite - Decreased
Sleep - Adequate
Bowel and bladder - Regular
No addictions.
DAILY ACTIVITY
Earlier at Hostel
5 am wake up
Gets ready by 6 am
6:30 am to the ground for yoga,exercises
7 am ragi Java
7.30 am prayer
8am classes
9.15 am breakfast
Classes until 1.30
1.30 to 2.30 lunch
2.30 to 4.30 study hour
4.30 to 5 snacks
5.00 to 6 pm walking ,playing
6 to 6.30 prayer
7 pm dinner
Till 9 pm study hour
9pm sleep
Now at Home
6am wake up
7 am tea
Breakfast and fruits
Tablets
Sleeps until afternoon
2.30 to 3 lunch
2 months after taking ATT her appetite was increased and she ate more food ,more frequently (5times a day).
Walking exercises
Evening 6pm fruits
Songs prayers
8pm dinner
9pm sleep
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative,well oriented to time,place and person.
Moderately build and malnourished.
Examination was done in a well lit room.
Pallor+
Pedal edema + ( grade 2)
No icterus, cyanosis,clubbing,lymphadenopathy
VITALS
BP:140/90 bpm
PULSE RATE:80/min regular normal volume
RESPIRATORY RATE: 26 cycles/min
Spo2 : 95%RA
Temperature chart
SYSTEMIC EXAMINATION
ABDOMEN
Inspection
Shape - Slightly distention.
Umbilicus - Everted
Equal movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
No scars , sinuses
Palpation
Soft, tenderness in right and left Hypochondrium, epigastrium.
Fluid thrill present
Percussion
Shifting dullness present
Auscultation
Bowel sounds heard
RESPIRATORY SYSTEM
Bilateral air entry present
Dull note all over
Vocal resonance decreased
CVS EXAMINATION
S1 S2 heard( Slightly muffled), no murmurs
Pericardial rub heard
CNS EXAMINATION
No focal neurological deficits
Higher mental functions normal
Cranial nerves normal
Sensory examination normal sensations
Motor examination normal
Reflexes normal
INVESTIGATIONS
Spot urine sodium 166mmol/l
Spot urinary potassium 20.5
ABG
PH 7.4
Pc02 14.9 mm hg
P02 79.8mm hg
Hc03 9.2 mmol/l
O2 saturation 96%
SERUM ELECTROLYTES on 14\3
Sodium 136 meq/l
Potassium 4.4 mEq/l
Chloride 106 meq/l
Serum creatinine 0.6mg/dl
ESR 70 mm
CRP NEGATIVE
Blood urea 29 mg\dl
FBS 100 mg\dl
Blood group 0+
Rheumatoid factor negative
HIV non reactive
Hbs ag non reactive
URINE EXAMINATION
Colour pale yellow
Appearance clear
Acidic
Specific gravity 1.010
Albumin ++
No sugar, bile salts, bile pigments, rbc, crystals, casts, amorphous deposits
Pus cells 3 to 4 \hpf
Epithelial cells 2 to 3 \hpf
USG
Liver,gallbladder,pancreas,spleen, uterus,ovaries normal
Moderate ascites
Bilateral pleural effusion
Moderate pericardial effusion
Bilateral grade 2 RPD changes
COMPLETE BLOOD PICTURE
Hb 7.5 g\dl
WBC 4200 cells\cumm
Neutrophils 60
Lymphocytes 36
Eosinophils 02
Monocytes 02
Basophils 0
Pcv 24.6 vol%
Mch 76.4 fl
Mchc 30.5%
Rdw 20.6 %
Rbc count 3.2 million\cumm
Platelet 1.57 laksh\cumm
Smear normocytic normochromic anemia
On 15\3
Serum creatinine 1.0 mg\dl
Sodium 1.37 meq\l
Potassium 4.7
Chloride 104
Spot urine protein 393 mg\dl
Spot urine creat 37.8 mg\dl
Ratio 10.3
ECG
TREATMENT
Fluid restriction ( 1.5 L/day)
Salt restriction (1.2 GM/day)
Inj lasix 40mg IV BD
Inj Monocef 1gm IV BD
Inj Methyl prednisolone 250mg in 100ml NS IV OD
Tab Aldactone 25mg PO OD
Tab Shelcal 500mg PO OD
Vitals monitoring
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