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


Comments

Post a Comment

Popular posts from this blog

A 42 Year old male with Altered Sensorium

Image
August 16,2022 Chief Complain : A 42 year old male was brought to casuality in a state of altered sensorium with history of fever since 10 days , vomiting since 10 days , generalised weakness and drowsiness since 10 days. HOPI : Patient was asymptomatic 1.5 years ago and then developed involuntary movements of upper limb and lower limb associated with uprollong of eyes and for which he was taken to alocal hospital and was diagnosed to be having alcoholic encephalopathy and dyseloctrolytemia for which he was treated conservatively and was discharged in a hemodynamically stable condition.  From then he was asymptomatic until 10 days ago , when he developed fever which is of low grade and relieved on medication and developed generalised weakness and vomiting 4-5 episodes in a day and the content are food particles and non- bilious and also associated with nausea. C/O generalised weakness and drowsiness since 10 days. With above complains patient visited multiple hospitals and received sym
Read more

GENERAL MEDICINE E-lOG

Image
31 YEAR OLD MALE WITH POST RENAL TRANSPLANTATION ARUSHI KUMARI 151    This is an 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 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 valuable inputs on the comment . A 31 year old male , K/C/O CKD stage 5 with renal transplantation done came for regular check up . History of Presenting Illness -   Patient was apparently asymptomatic 5 years back . * Sequence of events  - In 2017 , patient started feeling generalised weakness along with blood in vomiting for which he consulted local doctor .  - The doctor asked for CBC which showed he is anaemic . - Till 2018 he and on and off
Read more

55 YEAR OLD MALE WITH GIDDINESS AND LETHARGY

Image
Arushi Kumari  Roll no. 151 55 year old male painter by occupation came to casualty with cheif complaints of  1.Giddiness since 2 days 2.lethargy since 1 day - Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom where he fell down on his knees, no LOC,No involuntary movements of UL/LL. - He was taken to outside hospital found out to be having BP-250/120mm of hgand so  antihypertensives were given. - 1 day back patient was brought  here with lethargy,  decreased responsiveness for further evaluation. - On presentation to casualty , he had   BP: 180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg. Past history: K/C/O HTN since 2 years and on irregular medication,Not a K/C/O DM, Bronchial asthma,CAD. Family History No family history of HTN, DM, bronchial asthma, epilepsy. General examination:-  - Patient is conscious,coherent, cooperative,oriented to time,place and person. - No signs pallor,icterus,cyanosis,lympha
Read more