This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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.
CASE:
A 13 year old female patient who is resident of Suryapet came to the opd with chief complaints of shortness of breath since 3days and vomitings at night 3 days back(13-3-2023).
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2years back she was then sent to hostel when she noticed bilateral swellings in the neck around 5 in number which where painless
She also had fever Which was insidious in onset,intermittent with evening rise of temperature which relieved with medication.
She also had cough which was dry and non productive, no hemoptysis ,relieved with medication from RMP (cough syrup).
She had all these symptoms for 2 to 3 months
Then she consulted RMP and he gave them medication probably ATT because her mother has tuberculosis
Swellings size decreased and symptoms were relieved.
But the fever was progressively increasing despite regular treatment so they told rmp about it and stopped using ATT.
And RMP suggested them to go for checkup in hospital and they went to hospital in Hyderabad and got tested (fnac,cancer tests, tb tests, mantoux, sputum culture, cbnaat).
And got admitted for 10 days and recieved symptomatic treatment
(She also had complaints of joint pains wrist and knee)
They suspected it to be automimmune and started her on hydroxychloroquine and wysolone tab which they used for 15 days.
ANA ELISA equivocal
ANA IFA negative
ANTI DS DNA ELISA positive
ANTI DS DNA IFA negative
She went back home
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 3 months,pitting type.
Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis.
LN biopsy was done
Mycobacterial gene expert test was done.
So they started her on ATT and recieved regular treatment for 6months.
Her symptoms settled and she was fine until January 10 when she develop generalized edema.
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 she had episodes of vomiting 4 episodes ,food as content, non bilious and non projectile.
She also developed sob grade 2 and they got her here at 5.30 -6 am.
In 5th class her weight was 28kgs then in 6th class 23kgs,8th class 21 kgs
After ATT treatment her weight got improved to 23kgs that is last year
In December 26kgs,yesterday it was 25kgs.
DAily ROUTINE:
In 5th she went to hostel
During 7th class she started having these symptoms
After 7th she stopped school as it got worse and she was frequently visiting hospitals.
She went to hostel again after her ATT treatment and subsidence of symptoms in December.
Was fine until January and she came back home again .
In hostel previously :
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
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
Eve 6pm fruits
Songs prayers
8pm dinner
9pm sleep
PAST HISTORY:
She is a known case of Tuberculosis 1year back.
Not a known case of Hypertension, diabetes mellitus, asthma, epilepsy, CAD.
TREATMENT HISTORY:
History of ATT therapy 1 year back for 6 months.
PERSONAL HISTORY
Diet:mixed
Appetite: normal
Bowel bladder movements oliguria, bowel normal
Sleep decreased
Addictions none
FAMILY HISTORY:
Mother was diagnosed with TB in 2014 and
Used ATT course was not taken completely.
She used ATT when she had symptoms for 1 to 2 weeks
And stopped after symptoms subside
Symptoms got worse in 2022 and she died in sept 2022.
BIRTH HISTORY:
She is 1st born child
2nd degree consanguineous marriage
Lscs
Father has no idea about immunisation status
Menstrual history
Not attained menarche .
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
Well oriented to time place and person
Patient examined in well lit room
Pallor present
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema present
VITALS:
Temperature: afebrile
Bp 130\80mmhg
Pulse rate 110 bpm regular, normal volume
Respiratory rate 32 cpm
Sp02 99%.
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
Inspection:
Shape - slight 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
No bruit or venous hum
RESPIRATORY SYSTEM :
Bilateral air entry present
Dull not
Vocal resonance decrease.
CVS EXAMINATION:
S1 s2 heard, no murmur
Pericardial rub is present
JVP Raised
CNS EXAMINATION
No focal neurological deficits.
Higher mental functions-normal
Cranial nerves-normal
Sensory examination-normal.
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/lcc
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
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 to4 \hpf
Epithelial cells 2 to 3 \hpf
X-ray chest:
On usg
Liver,gallbladder,pancreas,spleen, uterus,ovaries normal
Moderate ascites
Bilateral pleural effusion
Moderate pericardial effusion
Bilateral grade 2 rpd change
Hemogram:
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
Fever chart:
PROVISIONAL DIAGNOSIS :
Automimmune disease (most probably SLE)
Glomerulonephritis secondary to lupus
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.
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