1801006024-LONG CASE

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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. is an 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.

13 Years old female student by occupation came to casuality with

CHIEF COMPLAINTS:

Shortness of breath since 2 days (decreased now)

4 episodes of vomitings since 2days 10pm

HISTORY OF PRESENTING 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 she has bilateral neck swellings 

So she was taken to RMP with complaints of neck swellings,fever and cough on and off

RMP has initiated her on ATT as her mother has also has Tb

They used ATT for 2months started in 2021 june

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

Patient was taken to hospital where she was evaluated for kochs but none of the investigations showed AFB,at that time she also had complaints of knee pains and wrist joint pains

In view of joint pains she was referred to x hospital 

In X hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped and later did not go there for follow up 

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.

10-15days before starting ATT attendors have noticed that she is developing facial rash and Hair loss,due to hair loss scalp rash also became evident.

PAST HISTORY  :

 Known case of  tb (1year back used att for 6 months)

N/k/c/o hypertension, DM, epilepsy, Asthma 

BIRTH HISTORY:

1st child 

2nd degree consanguineous marriage 

Born in 2010

LSCS - delivery 

Father has no idea about immunisation status

FAMILY HISTORY :

2014 mother diagnosed with TB-expired in 2022 sept(did not use ATT regularly)

PERSONAL HISTORY:

Diet - Mixed

Appetite - Decreased appetite  

Decreased urineoutput 

Sleep - adequate 

Addictions - None

TREATMENT HISTORY :

Used Anti Tubercular therapy for 6 months for extra pulmonary tb.

GENERAL EXAMINATION : 

The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 

Moderately built and Moderately nurished 

Pallor is present 

Edema of Lower Limbs is present 

No icterus, cyanosis, clubbing, lymphadenopathy 

VITALS:

,Temp: 98.4 F

PR: 126 bpm

BP: 130/90 mm Hg

RR: 26 cpm

SPO2: 98% 

SYSTEMIC EXAMINATION : 

Patient is examined in a well lit room and in a sitting position

RESPIRATORY SYSTEM:

Bilateral Air entry present

Vocal resonance is decreased in affected area 

Dull note on percussion in affected region 

C V S :

S1,S2 heard

Pericardial rub 

No murmur

PER ABDOMINAL EXAMINATION:

INSPECTION:  Shape of Abdomen - mild distended, No sinuses, fistulas. Umbillicus - Central, not everted

PALPATION: Inspectory Findings Confirmed

Soft, Tenderness present in right and left hypochondrium

Epigastrium 

PERCUSSION : Shifting dullness

AUSCULTATION: Bowel sounds Heard

C N S :

No focal neurological deficits 

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION :

Normal sensations felt in all dermatomes

MOTOR EXAMINATION :

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES:

Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION :

Normal function

No meningeal signs were elicited

INVESTIGATIONS :

ECG - 

Hemogram :

HB -6.8 gm/dl 

Mcv - 77.4fl

MCHC -29.2%

MCH-22.6%

Peripheral smear - Anisopoikilocytosis with macrocytes ,tear drop ,microcytes 

 Other investigation: 

On spot urine protein -10gm/dl

 

Findings - 

Moderate ascitis 

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral Grade 2 RPD  

Chest x ray - 

Clinical images  

Tubercular drugs used in past :

DIAGNOSIS : 

?Autoimmune disease ? Glomerulonephritis secondary to ? Lupus

TREATMENT : 

1. FLUID RESTRICTION LESS THAN 1.5L/DAY

2. SALT RESTRICTION LESS THAN 1.2GM/DAY

3. INJ. LASIX 40 MG IV/BD

4. INJ. METHYLPREDNISOLONE 250 MG IN 100ML NS IV/OD

5. TAB. ALDACTONE 25MG PO/OD

6. TAB. SHELCAL 500 MG PO/OD

7 VITALS MONITORING