Final Practical Long Case

Final practical

 Arushi Kumari

roll.no-151

MBBS 9th semester 

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’ve 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.

45 Year old female with Rash 

June 07, 2022 

A 45 year old female , tailor by occupation came to the hospital with chief complain of 
- On and off fever with generalized body pain since 3 months 
- loss of appetite since 3 months 
- itchy facial rash since 5-6 days 

History of Presenting Illness
* Patient was apparently asymptomatic 10 years back when she devedoped joint pain which was gradual in onset and of fleeting type which was associated with morning stiffness which usually used to last for 10 mins and was not associated with swelling .
- Patient went to some private hospital where she was treated for the same for two months and found to be RA positive . 

* Patient remained asymptomatic after being treated and since 8 months back when she developed joint pain in the metacrpophalangeal joint and knee joint following injection of 1st dose of covishield . She was treated with Inj. Diclofenac for 5-6 days and pain releived in 20 days . 

* One month back patient had an episode of loss of consciousness with cold peripheries and sweating after taking Tablet Glimi M2 prescribed by the doctor for her high sugar level ( around 250 mg /dL ) .

* 10 days back patient developed fever and abdominal pain for which she was treated at a private hospital .

- Later she developed an erythematous rash over the face which was associated with  itching ( increased on sun exposure)
Lesion was describe as diffuse erythematous and hyperpigmented papules ans pustules were noted over the bilateral cheeck sparing the nasolabial fold . ( Drug rash ? )

* Swelling of the left leg over the lateral aspect with erythema and local rise of temperature (? Cellulitis )

- loss of weight since 2 months 

Past History :
* Patient had a history of diminution of vision at age of 15 years started using  spectacles but there was gradual, progressive, painless loss of vision was diagnosed as Optic atrophy with macular degeneration . 

- Not a known case of DM , asthma , TB , COPD , epilepsy .
- No relevant drug, trauma history present.
- No similar complaint in the past 

Personal History :
 Diet- mixed

Appetite- decreased

Bowel and bladder- regular

Sleep- disturbed

Addictions- nil


Familar History :
 Patient's sister had a similar history of joint pain in the past .

General Examination :
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
she is conscious, coherent and cooperative, thinely built and nourished.

Pallor  +

no icterus 

 No cyanosis

 No clubbing 

no lymphadenopathy 

No edema.

VITALS:

Patient was afebrile at the time of presentation .

BP: 110/70bmmHg ,B/L

PR: 72bpm , regular and normal                    volume,felt bilaterally

RR:18 cpm

SpO2 : 98 with RA

LOCAL EXAMINATION:

left lower limb swelling was present  at ankle associated with redness and local rise of temperature and dorsalis pedis  pulses were felt.

SYSTEMIC EXAMINATION

CVS

Inspection:

no scars on the chest

 no features of raised JVP no additional visible pulsations seen

Palpation 

all inspectory findings are confirmed

apex beat normal at 5th ics

no additional palpable pulsations or murmurs

percussion showed normal heart borders

auscultation S1 S2 heard no murmurs or additional sounds

CNS: C/C/C

MOTOR-: normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++


SENSORY :

touch, pressure, vibration, and proprioception are normal in all limbs

GIT:

inspection- normal scaphoid abdomen with no pulsations and scars

palpation - inspectory findings are confirmed

no organomegaly, non tender and soft 

percussion- normal resonant note present, liver border normal

auscultation-normal abdominal sounds heard, no bruit present

RESPIRATORY:

inspection: normal chest shape bilaterally symmetrical, mediastinum central

no scars, Rr normal, no pulsations

palpation: Inspectory  findings are confirmed 

percussion: normal resonant note present bilaterally

 

Related Images






Plain rasiograph of hand 


X-ray chest PA view 


Reports :

                         US abdomen 



              US scan of whole abdomen

                      TSH parameter 


Impression : 
Raised RA factor 
Raised SGPT and SGOT 

Special tests 

                 Hematology Report 
Impression :
Normocytic hypochromic ( Hb 6.0 )
Mild decrease in Platelet count 
Relative monocytosis 


Overall Investigations :

RBS: 136mg/dl

HEMOGRAM:

HB: 6.9
TC: 9700
MCV: 85.1
PCV: 21.7
MCH: 27.1
MCHC: 31.8
PLT: 1.57
ESR: 90
SMEAR: ANISOCYTOSIS

RFT:

Blood Urea: 20mg/dl
S. Creatinine: 1.1mg/dl
Na: 136
K: 3.3
Cl: 98

LFT:

TB: 0.45
DB: 0.17
AST: 60
ALT: 17
ALP: 138
TP: 6.3
ALB: 2.18

CUE:

ALB +
Sugars nil
Pus cells nil

ESR - 90

CRP - NEGETIVE

HCV: NEGETIVE

HBV: NEGETIVE

HIV: NEGETIVE

Shirmer test : Investigation of choice




                    Fig : ANA report 


Teeatment History 

On 1st day ( 02/06/22 )

Inj. Piptaz 4.5 gm / iv / tid 

Inj. Metrogyl 600 mL /iv / tid 

Inj. Neonol 1 gm /iv / SOS ( if temp more than 101 F )

Tab. Chymoral forte PO/ TID 

Tab Pan 40/ PO/ OD 

Tab teczime 10 mg / PO/ OD

Hydrocortisone cream 1 per cent / OD face * week

Tab Orofer XT / OD

Inj. Nervz 1 amp in 100 mL NS 

On day 2 ( 03/08/22 )

Inj. Piptaz 4.5 gm / iv / tid 

Inj. Metrogyl 600 mL /iv / tid 

Inj. Neonol 1 gm /iv / SOS ( if temp more than 101 F )

Tab. Chymoral forte PO/ TID 

Tab Pan 40/ PO/ OD 

Tab teczime 10 mg / PO/ OD

Hydrocortisone cream 1 per cent / OD face * week

Tab Orofer XT / OD

Inj. Nervz 1 amp in 100 mL NS 

On day 5 (06/06/22 )

Tab Deflezacort  6mg / PO /BD 

Tab Cefixime 200 mg / PO / BD 

Tab. Orofer XT / PO / OD

Tab. Teczine 100 mg / PO/OD

Tab Rantac 150 mg / PO/OD

Hydrocortisonebcream 1 per cent OD for face * 1 week

 

Onlast day ( 07/07/22 )

Tab Deflezacort  6mg / PO /BD 

Tab Cefixime 200 mg / PO / BD 

Tab. Orofer XT / PO / OD

Tab. Teczine 100 mg / PO/OD

Tab Rantac 150 mg / PO/OD

Hydrocortisonebcream 1 per cent OD for face * 1 week











PROVISIONAL DIAGNOSIS: 

? Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with Left  Lower limb cellulitis 

B/L Optic atrophy


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