Tuesday, 29 March 2022

Medicine prefinal case discussion

Name: Ramya reddy pebbeti

Roll no: 105

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian 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 the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble 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

Following is the view of my case :

CASE PRESENTATION ;
DOA;14/3/22
CHIEF COMPLAINTS;

A 48 year old female resident of hyderabad, homemaker, presented to the OPD with the complaints of 
  • SOB since 1 month(Initially grade 2 progressed to grade 3)
  • Pedal edema since 1 month
  • Generalized weakness and fatigue since 1 month
  • Difficulty in opening mouth and oral ulcers since 1 week
  • Difficulty in swallowing for both solids and liquids since 4 days
HOPI;

She recieved NSAIDS ,HCQ, PREDNISOLONE FOR RA and she stopped

3 months back around 3/1/22,she was taken to hospital for SOB ,pedal edema , fever where she is diagnosed to have miliary tb (HRCT) she is started on medication(ATT) BUT after 15 days of using she noticed peeling of skin and redness all over her body for which she went to another hospital where she got treated and she stopped ATT ,and in mid Feb she again started ATT and she was fine for 10 days and then on 7/3/22 she c/o SOB, Difficulty in opening mouth and also difficulty in swallowing and burning micturition and fever.

Past History;

_No similar complaints in the past
_She has hypertension, since 10 years (On medication regularly)
_Diabetes since 6 months
_Hypothyroidism since 8 years(On medication regularly)
_Known case of TB since 3months

Personal history:

Diet- Mixed
Appetite- Reduced
Bowel and bladder- Regular
Sleep- Adequate
No history of any addictions
No known allergies

Family history;

No history of tuberculosis in the family


General examination;

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

Pallor- present
Icterus- Absent
Cyanosis- Absent
Clubbing-Absent
Lymphadenopathy- Absent
Edema- Present (Non pitting)

Vitals (On admission)-
Temperature- Febrile(Low grade)
Pulse rate- 98bpm)
Respiratory rate- 30cpm
BP- 130/90 mm/Hg
SPO2- 95% at room hair
GRBS- 105 gm%

Head to toe examination;

Alopecia- present
Eyes- Proptosis seen
EOM- Intact
Tongue- ulcers 
Thyroid- No goitre
Skin- Multiple hyperpigmented macules all over the face, upper limbs, lower limbs, abdomen and trunk, skin is dry, thickening of skin noted over the forearms, dorsum of hand, and around the mouth, absent of hair, slight peeling is noted over limbs(both) now





















Systemic examination;

RS;
  #Inspection-
 Shape of chest- Bilaterally symmetrical
 Position of trachea- Central
 Movements of chest appears to be equal
 No scars and sinuses

 #Palpation-
 Movements decreased in left mammary  and Inter scapular area
 Vocal fremitus decreased

 #Percussion-
Dull note in left mammary and interscapular
 
#Auscultation-
Decreased air entry on left side
Coarse crepitations heard on interscapular area

CVS-;
S1 and S2 heard
No murmurs heard

Per abdomen-;
Soft and non tender
Bowel sounds are heard

CNS-;
HMF - NORMAL
MOTOR SYSTEM;
MUSCLE POWER - initially it was grade 2 now she is fine with grade 4

Provisional diagnosis;

*Miliary tuberculosis 
*?Erythroderma secondary to ?Isoniazid

Investigations-

Sputum smear;


BAL;





Hemogram:

Hb- 7.2 gm%
TC- 15000 cu/mm
MCV- 80.4
MCH- 27
MCHC- 33.6
PCV-21.5
Peripheral smear- Normocytic normochromic
Serum Iron- 45microgram/dl

ABG;
pH- 7.34
PCO2- 18.8
PaO2- 92.4
HCO3- 12.2
SPO2- 96%

RBS;70 mg/dl
HbA1c;6.8%

LFT;

TB- 2.8
DB- 0.74
AST- 14
ALT- 10
ALP- 673
TP- 7.4
Albumin-2.23

RFT;

Blood Urea: 136mg/dl 
S. Creatinine: 4.8mg/dl
Na- 139
K- 3.0
Cl -102


CUE;

Albumin- positive
Pus cells- plenty
Epithelial cells- 1-2

ESR- 180

CRP- 1.2 mg/dl

RA factor- Negative

LDH- 326IU/L

Chest X-ray;




XRAY neck - lateral view;




ECG;




USG abdomen;



HRCT chest;




Repeat HRCT ;23/3/22





On 29/03/22 ,
ANA PROFILE AND SERUM FERRITIN were sent .

Treatment;




Ivfluids- NS/RL/DNS (75 ml/hr)
Inj. NaHCO3- 50mEQ over 10 minutes + 50mEQ over 40 minutes
Nebulization- Budicort inhalational TID
Inj. Insulin (actrapid)-according to sliding scale
Inj. PIPTAZ- 2.25 gm IV TID
Tab. Thyronorm- 50mcg PO OD
Inj. PAN- 40 mg IV OD
Tab. AMLONG- 5 mg PO OD
MUCOPAIN gel for oral ulcers
Betadine mouth wash TID
Liquid paraffin all over the body