Thursday, March 16, 2023

1801006052 Long case



 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 


 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 13 year old female patient resident of    Suryapet presented to OPD with 

CHIEF COMPLAINTS

Vomitings  since 1 day  

Shortness of breath since 1 day

HISTORY OF PRESENTATION ILLNESS

 Patient was apparently asymptotic till the age of 11years

She was sent to hostel for studies

After few days of hostel stay she noticed that bilateral swellings  over the neck 5-6 in number 

History of fever which is insidious in onset,intermittent, not associated with chills and rigors no evening rise of temperature 

History of cough which is intermittent and not associated with any sputum 

 for which she was taken to RMP, he  has initiated her on ATT as her mother has also has Tuberculosis 

They used ATT for 2months started in the month of June 2021

After initiating ATT fever was  increased so they discontinued ATT and was referred to Hyd by the RMP

Patient was taken to hospital where she was evaluated for tuberculosis  but was tested as negative for Acid fast bacilli, culture,cbnaat. ,she also  complained  of  bilateral knee and wrist joint pains.

In hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped.

Patient was tested for -

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 the month of May 2022

Mycobacterial gene expert test was done and was confirmed with Tuberculosis and was started on ATT for 6 Months.

 Before starting ATT attendors had noticed that she is developing facial rash  ( black in colour)  rash all over the body and Hair loss.

Patient was fine till the month of January 2023 ,she developed generalised edema due to proteinuria. 

Fever was on and off from then which got  relieved on taking medication.

Pedal edema  since 2 weeks  till the level of knee, Abdominal distension since 1 week .

March 13: She had Vomitings 4 -5 episodes non  bilious ,food as content.

Shortness of breath of grade 2 


PAST HISTORY:

Patient is a known case of Tuberculosis, diabetes, Hypertension, epilepsy,asthma.

PERSONAL HISTORY:

Daily routine - Patient wakes up at 7 am does her daily routine work , previousy she used to stay at hostel ,goes to school at 9 am ,lunch at 1 pm ,comes back from school  take some snack ,playtime till 6 pm, dinner at 7 :30 pm and goes to sleep at 10 pm .

Now patient wakes up at 7 am does her routine work,take break fast at 9 am and takes rest lunch at 1 pm ,snacks ,fruits at 4:30 ,8 pm dinner,9 pm sleep.

Appetite - decreased.

Diet - Mixed

Bowel and bladder movements: patient complained of decreased urine output,bowel movements are normal .

Sleep: inadequate 

FAMILY HISTORY:

Mother is a known case of Tuberculosis ,died 6 months ago 

BIRTH HISTORY: She is the first child born out of 2nd degree consanguineous marriage



MENSTRUAL HISTORY

Not attained menarche .


GENERAL EXAMINATION:

Patient is conscious coherent and cooperative ,well oriented to time place and person poorly built and moderately nourished .

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Bilateral pedal edema present




Vitals:

Temperature


 Pulse rate:88beats /min

Blood pressure:130/70

Respiratory rate:22cycles per minute.


SYSYTEMIC EXAMINATION:

Abdominal examination:

Inspection:

Shape - slightly distention.

Umbilicus - Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation:

soft, tenderness in right and left Hypochondrium, epigastrium.

Percussion:

shifting dullness present.

Auscultation:

Bowel sounds heard


Respiratory examination:

Bilateral air entry present

Dull note heard on percussion 

Vocal resonance decreased.


Cvs examination

S1 s2 heard, no murmurs

Jugular venous pressure:

https://youtube.com/shorts/nx6XLEUBxJY?feature =share



CNS examination:

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal

Motor examination normal

Reflexes normal.


INVESTIGATIONS:

14/03

Serum electrolytes:

Sodium 136 meq/l

Potassium 4.4 mEq/l

Chloride 106 meq/l


Serum creatinine 0.6mg/dl

Esr 70 mm

CRP neagtive

Blood urea 29 mg\dl

FBS 100 mg\dl

Blood group 0+

Rheumatoid factor negative

HIV non reactive

Hbs ag non reactive.


COMPLETE URINE EXAMINATION:

Colour pale yellow

Appearance: clear

Acidic

Specific gravity 1.010

Albumin ++

RBC: 4-6

No sugar, bile salts, bile pigments,  casts, amorphous deposits

Pus cells 3 to4 \hpf

Epithelial cells 2 to 3 \hpf


ULTRASOUND ABDOMEN:

Liver,gallbladder,pancreas,spleen, uterus,ovaries normal

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change


COMPLETE BLOOD PICTURE:

14/03:

Hb- 6.8g%

Wbc-5,400

Platelet:1,20,000

Pcv:23.3

MCv:77.4

Mch:22.6

Mchc:29.2

Rdw:20.1

RBC:3,01

Smear- Anisopoikilocytosis,with microcytes ,tear drop cells ,pencil forms.


15/03:

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


 16/03:

Hb-7.2g%

Pcv-23.7

Mcv-70

Mch: 22.1

Mchc:20.4

Rdw:20.


15/3:

Serum creatinine 1.0 mg\dl

Serum electrolytes:

Sodium 1.37 meq\l

Potassium 4.7

Chloride 104


Spot urine protein :393 mg\dl

Spot urine creat 37.8 mg\dl.


Chest X ray:


ECG:






PROVISIONAL DIAGNOSIS :

Autoimmune disease?
Glomerulonephritis secondary to Lupus.

CLINICAL IMAGES













TREATMENT:

Fluid restriction 

Salt restriction

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 .